Panel:
Medical Limited Coverage Policy Diagnosis Codes
DX Code Or Keyword:
Alpha-Fetoprotein
Aluminum
Antinuclear Antibodies
Benign Essential Hypertension
Blood Counts (ICD-9-CM Codes That Do NOT Support Medical Necessity)
CA 125
CA 15_3 (27.29)
CA 19_9
CEA
Collagen Cross Links
Creatinine Kinase (CPK); Total,
Cytogenetic Studies
Digoxin
Experimental Testing (Test Not Covered. Patient Must Sign ABN Form)
GGT
Glucose
Glycated Protein And Glycated Hemoglobin
Gonadotropin (hCG)
Helicobacter Pylori Testing
Hepatitis Panel
HIV
Immunodeficiency Virus
Iron Studies
Lipid Panel
Magnesium
Occult Blood, Feces
Prostate Cancer Screening
Prostatic Testing
Prothrombin Time
PSA
PTT
Syphilis
Thyroid Testing
Urine Culture
1. Choose the limited coverage test using the drop down box
2. Click on "Search"
3.The list of covered diagnoses will be displayed
OR
1. Choose the limited coverage test using the drop down box
2. Type the patient's diagnosis (all digits, including decimal) in the box
2. Click on "Search"
4. A description will appear for all covered diagnoses
