This article is for providers and labs who order or conduct the following tests: blood count, hepatitis panel, prothrombin time (PT), serum iron studies, thyroid testing, and urine culture
We recently announced a new medical policy for specific lab tests that will be effective April 1, 2021 for our commercial (HMO and PPO), Indemnity, and Medicare Advantage members. This policy will help to ensure coverage for necessary lab tests, while adhering to current best practices, and reducing medical spending waste. Below you’ll find more details about Diagnostic Laboratory Services medical policy 139 and what it means for your practice.
The Centers for Medicare & Medicaid Services (CMS) uses specific diagnoses to determine medical necessity for the following lab tests:
To see the diagnoses codes we’ll cover, please refer to CMS’ Clinical Diagnostic Laboratory Services national coverage determinations. We’ll include these diagnoses in the medical policy that will be posted on April 1.
Your patients may experience unexpected costs. If the claim for the CPT code does not have a covered diagnosis, the claim will deny for not meeting medical policy guidelines. We recommend that labs conducting these tests verify a covered diagnosis before performing the test to avoid rejected claims.
Our claims data suggests that many of these labs are ordered during routine well visits—even though medical literature suggests it’s not clinically indicated. This new medical policy will help to ensure that members are covered for medically necessary tests and helps reduce unnecessary health care spending.
Thank you for helping our members to receive tests that are clinically effective.