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New medical policy on coverage for lab tests
February 26, 2021

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.

"Most healthy people don’t need labs every year,” said Dr. Jamie Colbert, an internist and Blue Cross Blue Shield of Massachusetts’ senior medical director. “They aren’t necessary and in many cases are harmful because they can create the need for further testing, which can lead to unnecessary costs, stress, and worry."

Read: A new way to look at lab tests

We’ll use the same diagnoses as CMS to determine medical necessity

The Centers for Medicare & Medicaid Services (CMS) uses specific diagnoses to determine medical necessity for the following lab tests:

  • Complete blood count
  • Hepatitis panel
  • Prothrombin time (PT)
  • Serum iron studies
  • Thyroid-stimulating hormone (TSH)
  • Urine culture

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.

How to prepare for the new policy

  • Review the diagnosis codes for these coverage changes so you are aware of what codes will be covered for lab tests.
  • Continue to avoid routine testing if there is no clinical indication or risk factor.
  • Review your lab requisition order forms, especially pre-populated forms. If you use pre-populated forms, the tests ordered may not be covered for a well-visit diagnosis.
  • If your patient has received these tests as part of their routine physical, talk to them about why they are not needed annually or may not be necessary for their care.

What happens if the claim submitted does not include a covered diagnosis code?

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.

Why is Blue Cross making this change?

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

Thank you for helping our members to receive tests that are clinically effective.