Policy UpdatesMedicaidOctober 3, 2023

Lab testing reminder

Background

In February 2022, updates to Anthem Blue Cross and Blue Shield Healthcare Solutions Clinical Utilization Management Guidelines (CUMGs) were published with an August 1, 2022, effective date. These updates included changes to clinical coding edits for the following lab tests.

You can view appropriate CUMGs here.

Update

The updated guidelines state that only medically necessary lab testing will be covered. Effective January 1, 2024, coverage for these labs will be denied unless medically necessary:

CUMG number/title

Clinical indications for medical necessity

CG-LAB-24 – Urine Culture Testing

Clinical indications for medical necessity:

Outpatient urine culture testing for bacteria is considered medically necessary to evaluate any of the following situations:

  • Clinical signs or symptoms suggesting urinary tract infection (UTI); or
  • Abnormal urinalysis suggesting UTI; or
  • Asymptomatic bacteriuria in pregnant persons; or
  • Bacteriuria in individuals prior to undergoing an endoscopic urologic procedure; or
  • Suspected interstitial cystitis or bladder pain syndrome.

CG-LAB-25 – Glycated

Hemo Protein (A1c) Testing

Clinical indications for medical necessity:

Glycated serum protein testing (for example, hemoglobin (HbA1c), albumin, or fructosamine) testing is considered medically necessary for any of the following indications (A-F):

  1. The individual is between the ages of 35 and 71 and is overweight or obese*; or
  2. The individual is of any age, has overweight or obesity, and is from a population with disproportionately high prevalence of diabetes mellitus**; or
  3. Hyperglycemia has been found on other testing; or
  4. To test individuals who are pregnant and considered to be at high risk for type 2 diabetes mellitus; or
  5. Prior testing at least 3 months previously showed results near diabetes mellitus diagnostic thresholds; or
  6. To evaluate glycemic status for individuals with established diabetes mellitus, prediabetes, or a history of gestational diabetes when done no more often than the following test frequencies:
    1. Up to once yearly for individuals with prediabetes; or
    2. Up to two times per year for individuals with diabetes mellitus who are meeting treatment goals; or
    3. As needed to assess individuals with diabetes mellitus when the following criteria are met (a or b):
      1. Not meeting treatment goals; or
      2. Therapy has recently changed;
        or
    4. Within the first year postpartum and then up to once yearly for individuals who have had gestational diabetes.

CG-LAB-26 – Outpatient Alpha-Fetoprotein Testing

Outpatient alpha-fetoprotein testing is considered medically necessary for any of the following indications:

  1. Screening for neural tube defects in pregnant persons; or
  2. Evaluation or management of the following conditions:
    1. Carcinoma of unknown primary site; or
    2. Germ cell tumors; or
    3. Hepatocellular carcinoma (HCC): diagnosed HCC, suspected HCC, or for those at high risk for HCC; or
    4. Mediastinal mass; or
    5. Ovarian cancer; or
    6. Pelvic mass; or
    7. Retroperitoneal mass; or
    8. Testicular cancer or suspicious testicular mass; or
    9. Thymoma or thymic cancer.

CG-LAB-27 – Human Chorionic Gonadotropin Testing

Urine hCG testing is considered medically necessary for confirming the presence or absence of pregnancy. Blood hCG testing is considered medically necessary for any of the following indications:

  1. Confirming presence or absence of pregnancy; or
  2. Screening pregnant individuals for fetal abnormalities; or
  3. Hypertensive disorders of pregnancy; or
  4. Gestational trophoblastic neoplasia or molar pregnancy; or
  5. Evaluation of germ cell tumors; or
  6. Testicular cancer or suspicious testicular mass; or
  7. Ovarian cancer; or
  8. Pelvic mass; or
  9. Mediastinal mass; or
  10. Retroperitoneal mass; or
  11. Thymomas or thymic cancer; or
  12. Cancer of unknown primary

CG-LAB-28 – Prostate Specific Antigen Testing

Prostate specific antigen (PSA) testing is considered medically necessary for any of the following indications:

  • Screening for prostate cancer, or
  • Evaluation of signs or symptoms suggestive of prostate cancer; or
  • Individuals with previous elevated or rising PSA levels; or

Individuals with current or past history of prostate cancer.

What if I have questions?

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NVBCBS-CD-037377-23-CPN36786