tar and non cd8
TAR and Non-Benefit List: Codes 80000 – 899991
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
PATHOLOGY AND LABORATORY
ORGAN OR DISEASE-ORIENTED PANELS
80050General health panel...... 1
EVOCATIVE/SUPPRESSION TESTING
80400ACTH stimulation panel; for adrenal insufficiency.....1
80402ACTH stimulation panel; for 21 hydroxylase deficiency.1
80406ACTH stimulation panel; for
3 beta-hydroxydehydrogenase deficiency...... 1
80408Aldosterone suppression evaluation panel...... 1
80410Calcitonin stimulation panel...... 1
80412Corticotropic releasing hormone stimulation panel....1
80414Chorionic gonadotropin stimulation panel; testosterone response1
80415Chorionic gonadotropin stimulation panel; estradiol response1
80416Renal vein renin stimulation panel...... 1
80417Peripheral vein renin stimulation panel...... 1
80418Combined rapid anterior pituitary evaluation panel....1
80420Dexamethasone suppression panel, 48 hour...... 1
80422Glucagon tolerance panel; for insulinoma...... 1
80424Glucagon tolerance panel; for pheochromocytoma....1
80426Gonadotropin releasing hormone stimulation
panel...... 1
80428Growth hormone stimulation panel...... 1
80430Growth hormone suppression panel...... 1
80432Insulin-induced C-peptide suppression panel...... 1
80434Insulin tolerance panel; for ACTH insufficiency...... 1
80435Insulin tolerance panel; for growth hormone deficiency.1
80436Metyrapone panel...... 1
80438Thyrotropin releasing hormone (TRH) stimulation panel; one hour1
80439TRH stimulation panel; two hour...... 1
CONSULTATIONS (CLINICAL PATHOLOGY)
80500Clinical pathology consultation; limited...... 1
80502Clinical pathology consultation; comprehensive...... 1
URINALYSIS
81020Urinalysis; two or three glass test...... 1
MOLECULAR PATHOLOGY
Tier 1 Molecular Pathology Procedures
81162BRCA1, BRCA2, gene analysis; full sequence analysis and full duplication/deletion analysis2
81170ALB1, gene analysis, variants in the kinase domain...2
81200ASPA gene analysis; common variants...... 1
81202APC gene analysis; known familial variants...... 2
81205BCKDHB gene analysis...... 1
81209BLM gene analysis...... 1
81211BRCA1, BRCA2 gene analysis...... 2
81212BRCA1, BRCA2 gene analysis; 185delAG, 5385insC, 6174delT variants2
81213BRCA1, BRCA2 gene analysis; uncommon duplication/deletion variants2
81214BRCA1 gene analysis; full analysis...... 1
81215BRCA1 gene analysis; known familial variant...... 2
81216BRCA2 gene analysis; full sequence...... 1
81217BRCA2 gene analysis; known familial variant...... 2
81221CFTR gene analysis; known familial variants...... 1
81222CFTR gene analysis; duplication/deletion variants....1
81223CFTR gene analysis; full gene sequence...... 1
81224CFTR gene analysis; intron 8 poly-T analysis...... 1
81225CYP2C19 gene analysis...... 1
81226CYP2D6 gene analysis...... 1
81227CYP2C9 gene analysis...... 1
81228Cytogenomic constitutional microarray analysis; for copy number variants1
81229Cytogenomic constitutional microarray analysis; for copy number and single nucleotide polymorphism variants1
81230CYP3A4 (cytochrome P450 family 3 subfamily A member 4), gene analysis, common variant(s)1
81231CYP3A5 (cytochrome P450 family 3 subfamily A member 5), gene analysis, common variants1
81232DPYD (dihydropyrimidine dehydrogenase) gene analysis, common variant(s)1
81240F2 gene analysis...... 1
81241F5 gene analysis...... 1
81242FANCC gene analysis...... 1
81247G6PD (glucose-6-phosphate dehyfrogenase), gene analysis; common variant(s)1
81248G6PD (glucose-6-phosphate dehydrogenase), gene analysis; known familial variant(s)1
81249G6PD (glucose-6-phosphate dehydrogenase), gene analysis; full gene sequence1
81251GBA gene analysis...... 1
81252GJB2 gene analysis; full gene sequence...... 1
81253GJB2 gene analysis; known familial variants...... 1
81254GJB6 gene analysis, common variants and 232kb....1
81255HEXA gene analysis...... 1
81260IKBKAP gene analysis, common variants...... 2
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 80000 – 89999
April 2018
tar and non cd8
1
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
MOLECULAR PATHOLOGY (continued)
Tier 1 Molecular Pathology Procedures (continued)
81261IGH@ gene rearrangement analysis; amplified methodology1
81262IGH@ gene rearrangement analysis; direct probe methodology1
81263IGH@ variable region somatic mutation analysis.....1
81264IGK@ gene rearrangement analysis...... 1
81290MCOLN1 gene analysis...... 1
81291MTHFR gene analysis...... 1
81293MLH1 gene analysis; full sequence analysis...... 2
81296MSH2 gene analysis; known familial variants...... 2
81299MSH6 gene analysis; known familial variants...... 2
81302MECP2 gene analysis; full sequence analysis...... 1
81303MECP2 gene analysis; known familial variant...... 1
81304MECP2 gene analysis; duplication/deletion variants...1
81310NPM1 gene analysis...... 1
81313PCA3/KLK3 ratio...... 1
81318PMS2 gene analysis; known familial variants...... 2
81321PTEN gene analysis; full sequence analysis...... 2
81322PTEN gene analysis; known familial variant...... 2
81323PTEN gene analysis; duplication/deletion variant.....2
81324PMP22 gene analysis; duplication/deletion analysis...1
81325PMP22 gene analysis; full sequence analysis...... 1
81326PMP22 gene analysis; known familial variant...... 1
81327SEPT9 (Septin9) methylation analysis...... 1
81328SLCO1B1 (solute carrier organic anion transporter family, member 1B1), gene analysis, common variant(s)1
81330SMPD1 gene analysis...... 1
81331SNRPN/UBE3A methylation analysis...... 2
81332SERPINA1 gene analysis...... 1
81335TPMT (thiopurine S-methyltransferase), gene analysis, common variant(s)1
81340TRB@ gene rearrangement analysis; using amplification methodology1
81341TRB@ gene rearrangement analysis; using direct probe methodology1
81342TRG@ gene rearrangement analysis...... 1
81346TYMS (thymidylate synthetase) gene analysis, common variant(s)1
81350UGT1A1 gene analysis...... 1
81355VKORC1 gene analysis...... 1
Tier 2 Molecular Pathology Procedures
81400Molecular pathology procedure, Level 1...... 2
81401Molecular pathology procedure, Level 2...... 2
81402Molecular pathology procedure, Level 3...... 2
81403Molecular pathology procedure, Level 4...... 2
81404Molecular pathology procedure, Level 5...... 2
81405Molecular pathology procedure, Level 6...... 2
81406Molecular pathology procedure, Level 7...... 2
81407Molecular pathology procedure, Level 8...... 2
81408Molecular pathology procedure, Level 9...... 2
81479Unlisted molecular pathology procedure...... 2
GENOMIC SEQUENCING PROCEDURES AND OTHER MOLECULAR MULTIANALYTE ASSAYS
81410Aortic dysfunction or dilation; genomic sequence analysis panel, must include sequencing of at least 9 genes1
81411Aortic dysfunction or dilation; duplication/deletion analysis panel1
81412Ashkenazi Jewish associated disorders, genomic sequence analysis panel1
81415Exome; sequence analysis...... 1
81416Exome; sequence analysis, each comparator exome..1
81417Exome; reevaluation of previously obtained exome sequence1
81422Fetal chromosomal microdeletion(s) genomic sequence analysis, circulating cell-free fetal DNA in maternal blood1
81425Genome; sequence analysis...... 1
81426Genome; sequence analysis, each comparator genome1
81427Genome; re-evaluation of previously obtained genome sequence1
81430Hearing loss; genomic sequence analysis panel, must include sequencing of at least 60 genes1
81431Hearing loss; duplication/deletion analysis panel...... 1
81432Hereditary breast cancer-related disorders; genomic sequence analysis panel1
81433Hereditary breast cancer-related disorders; duplication/deletion analysis panel1
81434Hereditary retinal disorders, genomic sequence analysis panel1
81437Hereditary neuroendocrine tumor disorders; genomic sequence analysis panel1
81438Hereditary neuroendocrine tumor disorders; duplication/deletion analysis panel1
81440Nuclear encoded mitochondrial genes, genomic sequence panel, must include analysis of at least 100 genes1
81442Noonan spectrum disorders, genomic sequence analysis panel1
81445Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5–50 genes1
81450Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, 5–50 genes1
81455Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, 51 or greater genes1
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 80000 – 89999
January 2018
tar and non cd8
1
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
GENOMIC SEQUENCING PROCEDURES AND OTHER MOLECULAR MULTIANALYTE ASSAYS(continued)
81460Whole mitochondrial genome, genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection 1
81465Whole mitochondrial genome large deletion analysis panel, including heteroplasmy detection, if performed1
81470X-linked intellectual disability (XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes1
81471X-linked intellectual disability (XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes1
MULTIANALYTE ASSAYS WITH
ALGORITHMIC ANALYSES
81490Autoimmune, analysis of 12 biomarkers using immunoassays1
81493Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes1
81504Oncology, microarray gene expression profiling of 2,000 genes or more1
81507Fetal aneuploidy DNA sequence analysis of selected regions using maternal plasma2
81519Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes2
81525Oncology (colon), mRNA, gene expression profiling by real-time RT-PCT of 12 genes, utilizing formalin fixed paraffin-embedded tissue 1
81535Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology; first single drug or drug combination 1
81536Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology; each additional single drug or drug combination 1
81538Oncology (lung), mass spectrometric 8-protein signature1
81539Oncology (high-grade prostate cancer), biochemical assay of four proteins1
81540Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time
RT-PCT of 92 genes...... 1
81541Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a
disease-specific mortality risk score...... 1
MULTIANALYTE ASSAYS WITH
ALGORITHMIC ANALYSES (continued)
81545Oncology (thyroid), gene expression analysis of 142 genes2
81551Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy 1
81599Unlisted multianalyte assay with algorithmic analysis..2
CHEMISTRY
82075Alcohol; breath...... 1
82190Atomic absorption spectroscopy, each analyte...... 1
82757Fructose, semen...... 1
82777Galectin-3...... 1
83006Growth stimulation expressed gene 2...... 1
83937Osteocalcin...... 1
83950Oncoprotein, HER-2/neu...... 1
84112Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s), qualitative, each specimen1
84431Thromboxane metabolite(s), including thromboxane if performed, urine1
84449Transcortin...... 1
84586Vasoactive intestinal peptide...... 1
IMMUNOLOGY
86005Allergen specific IgE; qualitative, multiallergen screen..1
86152Cell enumeration using immunologic selection and identification in fluid specimen1
86153Cell enumeration using immunologic selection and identification in fluid specimen; physician interpretation and report1
86352Cellular function assay involving stimulation and detection of biomarker1
86386Nuclear matrix Protein 22, qualitative...... 1
TRANSFUSION MEDICINE
86890Autologous blood or component, collection processing and storage; predeposited1
86891Autologous blood or component, collection processing and storage; intra- or postoperative1
86910Blood typing; for paternity testing; ABO, Rh and MN, per individual1
86911Blood typing, for paternity testing; each additional antigen system1
86950Leukocyte transfusion...... 1
86965Pooling of platelets or other blood products...... 1
86985Splitting of blood or blood products, each unit...... 1
MICROBIOLOGY
87623Human papillomavirus (HPV), low risk types
(eg., 6, 11, 42, 43, 44)...... 1
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 80000 – 89999
January 2018
tar and non cd8
1
BenefitBenefit
CodeDescriptionRestrictionsCodeDescriptionRestrictions
ANATOMIC PATHOLOGY
Postmortem Examination
88000Autopsy, gross; without CNS...... 1
88005Autopsy, gross; with brain...... 1
88007Autopsy, gross; with brain and spinal cord...... 1
88012Autopsy, gross; infant with brain...... 1
88014Autopsy, gross; stillborn with brain...... 1
88016Autopsy; macerated stillborn...... 1
88020Autopsy, gross and microscopic; without CNS...... 1
88025Autopsy; with brain...... 1
88027Autopsy; with brain and spinal cord...... 1
88028Autopsy; infant with brain...... 1
88029Autopsy; stillborn with brain...... 1
88036Autopsy, limited; regional...... 1
88037Autopsy, limited; single organ...... 1
88040Autopsy; forensic examination...... 1
88045Autopsy; coroner’s call...... 1
88099Unlisted autopsy procedure...... 1
CYTOPATHOLOGY
88125Cytopathology, forensic...... 1
IN VIVO LABORATORY PROCEDURES
88738Hemoglobin, quantitative, transcutaneous...... 1
88749Unlisted in vivio (eg, transcutaneous) laboratory service2
REPRODUCTIVE MEDICINE PROCEDURES
89250Culture of oocyte(s)/embryo(s), less than 4 days...... 1
89251Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture1
89253Assisted embryo hatching, microtechniques...... 1
89254Oocyte identification from follicular fluid...... 1
89255Preparation of embryo for transfer...... 1
89257Sperm identification from aspiration (other than seminal fluid)1
89258Cryopreservation; embryo(s)...... 1
89259Cryopreservation; sperm...... 1
89260Sperm isolation; simple prep for insemination or diagnosis with semen analysis1
89261Sperm isolation; complex prep for insemination or diagnosis with semen analysis1
89264Sperm identification from testis tissue, fresh or cryopreserved1
89268Insemination of oocytes...... 1
89272Extended culture of oocyte(s)/embryo(s),
4-7 days...... 1
89280Assisted oocyte fertilization; </=10 oocytes...... 1
89281Assisted oocyte fertilization; >10 oocytes...... 1
89290Biopsy; </= 5embryos...... 1
89291Biopsy; >5 embryos...... 1
89300Semen analysis; presence and/or motility of sperm....1
89310Semen analysis; motility and count...... 1
89320Semen analysis; complete...... 1
89321Semen analysis; presence and/or motility of sperm....1
89322Semen analysis; volume, count, motility, and differential using strict morphologic criteria1
89325Sperm antibodies...... 1
89329Sperm evaluation...... 1
89330Sperm evaluation; cervical mucus penetration test....1
89331Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)1
89335Cryopreservation, testicular tissue...... 1
89337Cryopreservation, mature oocyte(s)...... 1
89342Storage, (per year); embryo(s)...... 1
89343Storage, (per year); sperm/semen...... 1
89344Storage, (per year); testicular/ovarian tissue...... 1
89346Storage, (per year); oocyte(s)...... 1
89352Thawing of cryopreserved; embryo(s)...... 1
89353Thawing of cryopreserved; sperm/semen...... 1
89354Thawing of cryopreserved; testicular/ovarian tissue....1
89356Thawing of cryopreserved; oocytes...... 1
89398Unlisted reproductive medicine laboratory procedure..2
Benefit Restriction Descriptions:1Non-Benefit3Assistant Surgeon services not payable
2Requires TAR,
Primary Surgeon/Provider
2 – TAR and Non-Benefit List: Codes 80000 – 89999
March2018