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PCR and Insurance coverage, coding, etc.

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#1 janne



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Posted 17 April 2013 - 07:48 PM

I am starting this new thread in order to keep Badger's thread intact with his question directed to BCBS of Illinois subscribers and the recent problem with PCR testing being covered.

I mentioned on his thread that I had queried a person specifically at  a BCBS technology evaluation center site.

This is the response I got from her today:

"I am responding to your email to Dr. Naomi Aronson at the Blue Cross and Blue Shield Association (BCBSA) Technology Evaluation Center (TEC).  BCBSA is an association for 39 independently owned and operated Blue Cross and Blue Shield Plans and their subsidiaries.  Each Blue Cross and Blue Shield Plan is a separate company and makes its own coverage decisions.

Since each Blue Plan is a separate company, you will need to contact the specific Blue Plan that holds your insurance to inquire about their policy on BCR-ABL testing.  You can get to their website by entering your 3-letter prefix in the " Go to Your BCBS Company and Log In" search box on the BCBSA website at

http://www.bcbs.com/already-a-member/ or you can go to the list of Blue Cross and Blue Shield plans by clicking on the link just below there called

"View all Blue Cross and Blue Shield Companies."  Alternatively, your Plan's contact information should be on the back of your Blue Cross and Blue Shield insurance card. 

Thank you for your interest in TEC."

Her response was rather avoidant and non-committal I thought as I perceived this to be "an evaluation site for technology" as implied by the name. The individual Plans (all 39 of them) have to get their "evidence" somewhere. But as she states, each Plan will have to respond.

The second thing I wanted to share was this website, which addresses the new coding. The way charges are billed is complex and coding has to be very accurate in order for it to not be kicked out of the system. I do not know if each of your denial responses was automated and was a result of inaccurate coding or NEW coding with other factors that conflicted. Someone mentioned that the response from BCBS was that the coding was incorrect. Please refer to this site and see if this helps. http://laboratorian....BL-Capture.aspx

Thirdly, I also obtained from two other sites, not necessarily pertaining to BCBS that the diagnosis or ICD-9 code has to be specifically 205.10 in conjunction with one of the three CPT codes mentioned on the previous website. It also sounds like they are trying to transition out of allowing this coverage. These are all bits and pieces I am picking up but because the issue of coding is so precise, this could have some bearing on some of your individual cases.

See below:

ICD-9 Codes that Support Medical Necessity:

It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Medicare is establishing the following limited coverage for the following diagnostic codes, with the anticipated expansion of such limited coverage as oncology biomarkers transition out of the initial Individual Consideration process for the remaining above services:

Covered for 81206, 81207 and 81208 (BCR-ABL)
ICD-9 CodeICD-9 Code Description

I do not know when  the other two codes allow for payment. I have only noticed this association with the first code and one of the three CPT codes.

Lastly, I recommend reading at this website which covers biomarkers such as PCR testing. https://www.novitas-...jh/dl33138.html. This company is affiliated with Medicare and it sounds like they are trying to limit payment under Medicare for the numerous test that are now available for so many conditions.

Medicare rules for medical necessity OFTEN but not ALWAYS dictate the path that other payors will follow. The following indicates a limited coverage for PCR testing for CML.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Unless otherwise specified, the biomarkers under limited coverage will be excepted only be performed once per lifetime, except for disease monitoring assays as  noted below:

  1. BCR-ABL (81206, 81207, and 81208): Any single service four times per Calendar year, but not enabling more than one code to be billed four times per Calendar year.

In the event that CODING is not the issue in each of your individual cases, I completely agree with getting your doctor involved. I do not think they will be happy once they find out the tests they depend on for monitoring their CML patients are not reimbursable under your insurance plan, if that turns out to be the case. I spoke to a coding expert today who tells me that when Medicare does not pay for certain tests that doctors consider to be vital in caring for their patients, there is an option for contesting that.

Dx'd: 8/2008. Started Gleevec 400 mg 11/08. 

Drug break 2011.

Started Tasigna 4/11 450 mg.

Reduction to 300 mg Tasigna 1/2012.

PCRU 9/2012.

12/2012 Detectable.

PCRU 4/2013 through 3/2015. (Reduced to 150 mg 7/2014)

12/2015  ? slightly detectable at probably less than 0.01% per Mayo Clinic.

4/2016 PCRU. Still at 150 mg Tasigna.


CESSATION: stopped treatment 7/20/2017. 

9/6/2017:  barely detectable at 0.01%. 

12/11/2017: PCR at 0.09% (did not do the monthly PCR testing.) 

12/18/2017: Inevitable call from Onc. Started back on Tasigna at 150 mg. (Considering Sprycel low dose.) 

#2 LLawrence


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Posted 17 April 2013 - 07:58 PM

This is scary but should wash out.  It is in no one's best interest (insurance, MD or patient) to have a test that is current standard of care denied.  When the patients and the doctors hit a critical mass of push back, it will get approved again (per my crystal ball).

#3 Badger


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Posted 18 April 2013 - 09:00 AM

Here's my experience. Last year a new single CPT code was supposed to be used for the PCR, instead of the six that were previously used. Last year the single code was always rejected and, after resubmitting it with the six codes, it was accepted. This year it has been reiected either way. For referenc, here's a link to the place that our billing goes through: http://www.cleveland...r_CPT_Codes.pdf

He single code that is supposedly being used now is 81206.

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