MolDx-05

Molecular Diagnostic Testing

Indicates Non-Covered Service

4Kscore Test -

Medicare

Acute Myeloid Leukemia Genetic Testing

AlloSure Donor-Derived Cell-Free DNA Test

APC & MUTYH Gene Testing

BRAF Mutation Analysis

Breast Cancer Index℠ Genetic Assay

Assays of Genetic Expression in Tumor Tissue as to Determine Prognosis in Patients with Breast Cancer

BRCA1 & BRCA2 Genetic Testing

-Anthem-

Gene Expression Profiling for Managing Breast Cancer Treatment

-Anthem-

MolDX: Breast Cancer Assay: Prosigna

Breast Cancer Index Genetic Assay

CADASIL Syndrome Genetic Testing

Gene Mutation Testing for Cancer Susceptibility & Management

-Anthem-

Gene Mutation Testing for Solid Tumor Cancer Susceptibility & Management

Genetic Testing for Diagnosis & Management of Hereditary Cardiomyop-athies (including ARVD/C)

Cardiac Ion Channel Genetic Testing

Carrier Testing for Genetic Diseases

-UHC-

Carrier Screening in the Prenatal Setting & Preimplantation Genetic Testing

-Anthem-

Cell-free DNA Testing for the Management of Cancer

-Anthem-

Cell-free Fetal DNA Testing

-UHC-

Genetic Testing

Charge Syndrome

-Anthem-

Chromosome 1p/19q Deletion Analysis

Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability & Congenital Anomalies

Circulating Tumor DNA Panel Testing (Liquid Biopsy)

-Anthem-

ConfirmMDx Epigenetic Molecular Assay

Comparative Genomic Hybridization (CGH) - Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions

Cutaneous Malignant Melanoma - Genetic Testing

CYP2C19, CYP2D6, CYP2C9, & VKORC1 Genetic Testing

Cystic Fibrosis - Genetic Testing

Genetic Testing for Inherited Diseases

-Anthem-

Genetic Testing for PTEN Hamartoma Tumor Syndrome

-Anthem-

Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status

Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing

MolDX: AlloSure® Donor-Derived Cell-Free DNA Test

MolDX: APC & MUTYH Gene Testing

MolDX:

BDX-XL2

MolDX:

Biomarkers In Cardiovascular

Risk

Assessment

-Anthem-

MolDX: CYSTATIN C Measurement

Cystic Fibrosis - Genetic Testing

MolDX Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low & Low Risk Disease

MolDX: Decipher® Prostate Cancer Classifier Assay

MolDX: DecisionDx-Melanoma

MolDX: DecisionDx-UM (Uveal Melanoma)

MolDX: EndoPredict Breast Cancer Gene Expression Test

DNA Analysis of Stool to Screen for Colorectal Cancer

Duchenne, Becker, Facioscapulohu-meral, & Limb-Girdle Muscular Dystrophies-

Geneic Testing

Ehlers-Danlos Syndrome Genetic Testing

Endocrine Gland Cancer Susceptibility Genetic Testing

EndoPredict Breast Cancer Gene Expression Test

MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test

Epilepsy -

Genetic Testing

Fanconi Anemia Genetic Testing

MolDX: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification Tests (NAATs)

FMR1 mutations (including Fragile X Syndrome) Genetic Testing

Gene Expression Profiling for Colorectal Cancer

MolDX: GeneSight ® Assay for Refractory Depression

MolDX: Genetic Testing for BCR-ABL Negative Myeloproli-ferative Disease

Genetic Testing for Breast, Ovarian & Pancreatic Cancer Susceptibility

Genetic Testing for Cardiac Disease

-UHC-

MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, & MTHFR)

Genetic Testing for Catechola-minergic Polymorphic Ventricular Tachycardia

Genetic Testing for Inherited Conditions

-Anthem-

Genetic Testing for Diagnosis and Monitoring of Cancer

-Humana-

Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP & MYH-associated Polyposis

MolDX: Genetic Testing

for

Lynch Syndrome & Other Inherited Colon Cancer Syndromes

-Anthem-

-FloridaBlue-

Genetic Testing For Neuro-degenerative

Disorders

Genetic Testing for TP53 Mutations

-Anthem-

MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay

Germline Mutations of the RET Proto-Oncogene - Genetic Testing

Molecular Analysis for Gliomas

MolDX: Guardant360 Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC)

Hereditary Cancer Testing

-Anthem-

Hereditary Hearing Loss - Genetic Testing

Hereditary Hemochrom-atosis - Genetic Testing

Hereditary Pancreatitis - Genetic Testing

Genetic Testing for Heritable Cardiac Conditions

Heterozygous Familial Hypercholester-olemia - Genetic Testing

MolDX:

HLA-B15:02

Genetic

Testing

MolDX:

HLA-DQB1*06:02 Testing for Narcolepsy

Inherited Cardiomy-opathies & Channel-opathies - Genetic Testing

Inherited Peripheral Neuropathies Genetic Testing

MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

Li-Fraumeni Syndrome - Genetic Testing

MolDX: MDS FISH

MolDX: MGMT Promoter Methylation Analysis

Mitochondrial Disorders Genetic Testing

MolDX: Molecular RBC Phenotyping

Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

Molecular Marker Evaluation of Thyroid Nodules

-Anthem-

MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels

MolDX: myPath Melanoma Assay

Neurodegener-ative Disorders -Genetic Testing

Neurofibroma-tosis & Related Disorders - Genetic Testing

Genetic Testing for Neuromuscular Disorders

-UHC-

MolDX NRAS Genetic Testing

MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC)

MolDX: Oncotype DX Breast Cancer for DCIS

MolDX: Oncotype DX Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer

MolDX: Percepta Bronchial Genomic Classifier

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions

-UHC-

Preimplantation Genetic Diagnosis Testing

-UHC-

Prenatal Genetic & Chromosomal Metabolic Testing

MolDX: Prolaris™ Prostate Cancer Genomic

Assay

MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease

MolDX: ProMark Risk Score

Mutation Analysis in Myeloprolif-erative Neoplasms

Prenatal Testing using cell-free DNA

-Anthem-

RET Proto-Oncogene Testing

-Aetna-

Rett Syndrome

Genetic Testing

Somatic Genomic Testing

-Anthem-

Alpha- & Beta-Thalassemia - Genetic Testing

TP53 Mutations

-Anthem-

Tumor Genetic Markers

-FloridaBlue-

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, & Molecular Profiling

Indicates Non-Covered Service

Concurrent DNA & RNA Genetic Testing

-Humana-

Gene Expression Profile Testing & Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

Gene Expression Profiling for Prostate Cancer

-Humana-

MolDX: Circulating Tumor Cell Marker Assays

MolDX: Corus CAD Assay

MolDx: Testing for Lyme Disease & Other Vector Borne Illness

-Humana-

MolDX: Prometheus IBD sgi Diagnostic Policy

-FloridaBlue-

Adolescent Idiopathic Scoliosis - Genetic Testing

Alzheimer’s Disease - Genetic Testing

-Anthem-

-FloridaBlue

Circulating Tumor DNA Panel Testing (Liquid Biopsy)

-Anthem-

Gene Expression Profile Tests for Multiple Myeloma

-Anthem-

Gene Expression Profiling & Genomic Biomarker Tests for Prostate Cancer

Gene Expression Profiling for Bladder Cancer

-Anthem-

Gene Expression Profiling for Cancers of Unknown Primary Site

-Anthem-

Gene Expression Profiling for Colorectal Cancer

-Anthem-

Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity

-Anthem-

Gene Expression Profiling of Melanomas

-Anthem-

Genetic Testing for Frontotemporal Dementia (FTD)

-Anthem-

Genetic Testing for Macular Degeneration

-Anthem-

Genetic Testing for Inherited Peripheral Neuropathies

-Anthem-

Genetic Testing for Statin-Induced Myopathy

-Anthem-

Genetic Testing to Confirm the Identity of Laboratory Specimens

-Anthem-

Lactase Insufficiency - Genetic Testing

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

-Anthem-

Paired DNA & Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose & Manage Cancer

Topographic Genotyping

-Anthem-

TruGraf Blood Gene Expression Test for Transplant Monitoring

-Anthem-