Article Detail - JF Part A

This coverage article has been revised and published for notice under contract numbers: 02101 (AK), 02201 (ID), 02301 (OR), 02401 (WA), 03101 (AZ), 03201 (MT), 03301 (ND), 03401 (SD), 03501 (UT), and 03601 (WY).

Effective Date: November 02, 2023

Summary of Article Changes: Under Article Text revised the 3rd and 6th bullets to remove "DEX Z-Code™" and replaced with "DEX Z-Code®". Added "NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line". Under subheading Additional information deleted third sentence and Table 1. This revision is effective 11/2/2023.

Under CPT/HPCS Codes Group 2: Paragraph added "The following test may be billed in the pre-biopsy setting as defined in the policy: SelectMDx assay (PLA 0339U), performed on post-digital rectal exam (DRE) urine specimens". Under CPT/HCPCS Codes Group 2: Codes added 0339U. Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph added "The following codes are covered". Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added D29.1, D40.0, N40.2, N40.3, and R97.20. The revision is due to new covered assay that has successfully completed a TA and is effective 2/17/2023.

Under Article Text removed the sentence: Medical record documentation must indicate the rationale for performance of such diagnostic biomarker tests as Noridian has modified certain language in the articles to mirror the language used presently by the MolDX team at Palmetto GBA as part of an annual review. Revision history dates and language may not exactly match the MolDX PGBA revision history. However, these revisions do not change coverage or guidance.

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