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Molecular Pathology Procedures Reminder

National Government Services has been receiving many claims submitted for redetermination that were submitted for Group 3 Molecular Pathology Procedures.

The Group 3 codes from LCD (L35000/A56199) are identified as Tier 1 Noncovered Codes for which genetic testing is unlikely to impact therapeutic decision-making in the clinical management of the patient.  These services are never payable by Medicare, and are automatically denied as not medically necessary when submitted, nor are they payable upon appeal.

We ask providers to refrain from submitting unnecessary appeal requests for these Group 3 Tier 1 Noncovered Codes as they will not lead to any change in adjudication. The CPT codes included in Medical Policy Article A56199: Billing and Coding: Molecular Pathology Procedures are listed here, and available in the article:

Group 3 Tier 1 Noncovered Codes (A56199)
81105-81112 81161 81171-81174 81200-81205 81228-81232 81234
81238-81244 81247-81255 81257-81260 81269 81271 81274
81283-81286 81289-81291 81302-81304 81324-81331 81336-81337 81346
81349-81350 81355 81361-81364 81410-81417 81420 81422
81425-81427 81430-81440 81442-81443 81448 81455 81460
81465 81470-81471 81493 81500 81503-81504 81507
81521 81525 81535-81536 81538 81540-81541 81551


If you believe any of the coverage information should be updated based on clinical data, you may submit a LCD Reconsideration to begin the discussion of a potential policy revision.

Submitting appeal requests for all of a claim type that denies will not lead to policy change and will incur a greater expense for practices.

Posted 3/29/2022