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NCD 190.3 – Cytogenetic Testing: Discretionary Diagnoses

Under National Coverage Determination 190.3, Cytogenetic Testing, CMS allows contractors discretion in coverage of specific Indications. “As this policy indicates, individual A/B MACs within their respective jurisdictions have the discretion to make coverage determinations they deem reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.”

We reviewed this NCD and have determined the discretionary diagnoses in the table below are payable.

Discretionary Diagnoses for NCD 190.3 – Cytogenetic Studies

ICD-10 Codes Description
C81.01–C81.09 Nodular lymphocyte predominant Hodgkin lymphoma
C81.11–C81.19 Nodular sclerosis Hodgkin lymphoma
C81.21–C81.29 Mixed cellularity Hodgkin lymphoma
C81.31–C81.39 Lymphocyte depleted Hodgkin lymphoma
C81.41–C81.49 Lymphocyte-rich Hodgkin lymphoma
C81.71–C81.79 Other Hodgkin lymphoma
C81.91–C81.99 Hodgkin lymphoma, unspecified
C82.00–C82.09 Follicular lymphoma grade I
C82.11–C82.19 Follicular lymphoma grade II
C82.21–C82.28 Follicular lymphoma grade III, unspecified
C82.31–C82.39 Follicular lymphoma grade IIIa
C82.41–C82.49 Follicular lymphoma grade IIIb
C82.51–C82.59 Diffuse follicle center lymphoma
C82.61–C82.69 Cutaneous follicle center lymphoma
C82.81–C82.89 Other types of follicular lymphoma
C82.91–C82.99 Follicular lymphoma, unspecified
C83.11–C83.19 Mantle cell lymphoma
C83.31–C83.39 Diffuse large B-cell lymphoma
C83.51–C83.59 Lymphoblastic (diffuse) lymphoma
C83.71–C83.79 Burkitt lymphoma
C83.81–C83.89 Other non-follicular lymphoma
C83.94 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb
C84.01–C84.09 Mycosis fungoides
C84.11–C94.19 Sezary disease
C84.41–C84.49 Peripheral T-cell lymphoma, not classified
C84.61–C84.69 Anaplastic large cell lymphoma, ALK-positive
C84.71–C84.79 Anaplastic large cell lymphoma, ALK-negative
C84.91–C84.99 Mature T/NK-cell lymphomas, unspecified
C85.11–C85.19 Unspecified B-cell lymphoma
C85.21–C85.29 Mediastinal (thymic) large B-cell lymphoma
C85.81–C85.89 Other specified types of non-Hodgkin lymphoma
C85.91–C85.99 Non-Hodgkin lymphoma, unspecified
C88.0 Waldenstrom macroglobulinemia
C88.8 Other malignant immunoproliferative diseases
C90.00–C90.02 Multiple myeloma
C90.10–C90.12 Plasma cell leukemia
C90.20–C90.22 Extramedullary plasmacytoma
C90.30–C90.32 Solitary plasmacytoma
C91.10–C91.12 Chronic lymphocytic leukemia of B-cell type
C91.30–C91.32 Prolymphocytic leukemia of B-cell type
C91.40–C91.42 Hairy cell leukemia
C91.50–C91.52 Adult T-cell lymphoma/leukemia (HTLV-1-associated)
C91.60–C91.62 Prolymphocytic leukemia of T-cell type
C91.A0–C91.A2 Mature B-cell leukemia Burkitt-type not having achieved remission
C91.90–C91.92 Lymphoid leukemia, unspecified
C91.Z0–C91.Z2 Other lymphoid leukemia
C92.30–C92.32 Myeloid sarcoma
C92.90–C92.92 Myeloid leukemia, unspecified
C92.Z0–C92.Z2 Other myeloid leukemia
C93.90–C93.92 Monocytic leukemia, unspecified
C93.Z0–C93.Z2 Other monocytic leukemia
C94.30–C94.32 Mast cell leukemia
C94.40–C94.42 Acute panmyelosis with myelofibrosis
C94.80–C94.82 Other specified leukemias
C95.10–C95.12 Chronic leukemia of unspecified cell type
C95.90–C95.92 Leukemia, unspecified
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.21–C96.29 Malignant mast cell tumor
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
D45 Chronic leukemia of unspecified cell type, in relapse
D47.01 Cutaneous mastocytosis
D47.02 Systemic mastocytosis
D47.1 Chronic myeloproliferative disease
D47.2 Leukemia, unspecified, in relapse
D47.3 Essential (hemorrhagic) thrombocythemia
D47.4 Osteomyelofibrosis
D47.9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified
D47.Z1 Post-transplant lymphoproliferative disorder (PTLD)
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D60.0 Chronic acquired pure red cell aplasia
D60.1 Transient acquired pure red cell aplasia
D60.8 Other acquired pure red cell aplasias
D60.9 Acquired pure red cell aplasia, unspecified
D61.01 Constitutional (pure) red blood cell aplasia
D61.09 Other constitutional aplastic anemia
D61.818 Other pancytopenia
D61.82 Myelophthisis
D61.89 Other specified aplastic anemias and other bone marrow failure syndromes
D61.9 Aplastic anemia, unspecified
D64.0 Hereditary sideroblastic anemia
D64.1 Secondary sideroblastic anemia due to disease
D64.2 Secondary sideroblastic anemia due to drugs and toxins
D64.3 Other sideroblastic anemias
D64.4 Congenital dyserythropoietic anemia
D64.9 Anemia, unspecified
D69.6 Thrombocytopenia, unspecified
D70.4 Cyclic neutropenia
D70.8 Other neutropenia
D70.9 Neutropenia, unspecified
D72.818 Other decreased white blood cell count
D72.819 Decreased white blood cell count, unspecified
D72.820 Lymphocytosis (symptomatic)
D72.821 Monocytosis (symptomatic)
D72.822 Plasmacytosis
D72.824 Basophilia
D72.828 Other elevated white blood cell count
D75.81 Myelofibrosis

Posted 4/11/2018

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Last Modified: 4/11/18
NCD 190.3 -- Cytogenetic Testing: Discretionary Diagnoses
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