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Medical Policy

Laboratory Section

Policy Name Policy ID Number Date Modified
Allergy and Sensitivity Tests of Uncertain Efficacy LAB01 09/01/2022
Analysis of Proteomic and Metabolomic Patterns for Cancer Detection, Risk, Prognosis, or Treatment Selection LAB41 02/01/2023
Biochemical and Cellular Markers of Alzheimer's Disease LAB22 01/01/2023
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover LAB23 10/01/2022

Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers

LAB46 02/01/2023
COVID-19 Testing LAB74 07/01/2022

Drug Testing for Substance Use and Pain Management

LAB68 07/01/2022
In Vitro Chemoresistance and Chemosensitivity Assays LAB06 07/01/2022

Invetigational Gene Expression, Biomarker, and Multianalyte Testing

LAB77 01/01/2023
Laboratory and Genetic Testing for Use of 5-Flurouracil  (5-FU) in Patients with Cancer LAB64 02/01/2022
Laboratory Tests for Organ Transplant Rejection LAB51 09/01/2022
Maternal Serum Analysis for Risk of Adverse Obstetric Outcomes LAB75 05/01/2022
Measurement of Lipoprotein-Associated Phospholipase A2 Lp-PLA2) in the Assessment of Cardiovascular Risk LAB63 07/01/2022

Measurement of Serum Antibodies to Selected Biologic Agents

LAB65 06/01/2022
Molecular Testing in the Management of Pulmonary Nodules LAB73


Multi-biomarker Disease Activity Blood Test for Rheumatoid Arthritis LAB67 10/01/2022
Multianalyte and Gene Expression Assays for Predicting Recurrence in Colon Cancer LAB76 12/01/2022
Multianalyte Assays with Algorithmic Analyses for the Evaluation and Monitoring of Patients with Chronic Liver Disease LAB47 09/01/2022
Multimarker and Proteomics-based Serum Testing Related to Ovarian Cancer LAB60 04/01/2022
Placental Rapid Immunoassay for Detection of Fetal Membrane Rupture LAB57 03/01/2022
Protein Biomarkers and Multi-analyte Biomarker Tests for Screening, Detection, and/or Management of Prostate Cancer LAB69 02/01/2023
Salivary Hormone Testing for Aging and Menopause LAB36 04/01/2022
Serum Holotranscobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status LAB44 04/01/2022
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance LAB72 02/01/2023

Vitamin D Testing

LAB52 02/01/2023