Jurisdiction 9 Review to Finalization Timelines for LCDs

LCD	Title	Comment Open	Comment End	Status*		Days in review
DL34217	Intensity Modulated Radiation Therapy (IMRT)	2/4/2016	4/10/2016	NRTF	N/A	381
DL36696	Hyperbaric Oxygen (HBO) Therapy	6/2/2016	8/8/2016	NRTF	N/A	261
DL36698	Intraoperative Neurophysiological Testing	6/2/2016	8/8/2016	NRTF	N/A	261
DL34213	Diagnostic and Therapeutic Colonoscopy	10/6/2016	12/15/2016	NRTF	N/A	132
DL34317	Chest X-Ray Policy	10/6/2016	12/15/2016	NRTF	N/A	132
DL34324	Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography	10/6/2016	12/15/2016	NRTF	N/A	132
DL36864	GlycoMark Testing for Glycemic Control	10/6/2016	12/15/2016	NRTF	N/A	132
DL36846	Measurement of Salivary Hormones	10/6/2016	12/15/2016	NRTF	N/A	132
DL34203	Cataract Surgery in Adults	2/8/2017	4/10/2017	NRTF	N/A	16
DL37120	4Kscore Assay	2/8/2017	4/10/2017	NRTF	N/A	16
DL37066	Coenzyme Q10 (CoQ10)	2/8/2017	4/10/2017	NRTF	N/A	16
DL37060	MolDX: Vita Risk™ Pharmacogenetic Test for Dry Age-related Macular Degeneration (AMD)	2/8/2017	4/10/2017	NRTF	N/A	16
DL37090	MolDX: VectraDA, a Multibiomarker Disease Activity Test for Rheumatoid Arthritis (RA)	2/8/2017	4/10/2017	NRTF	N/A	16
DL37054	MolDX: Xpresys Lung	2/8/2017	4/10/2017	NRTF	N/A	16
DL37086	Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder	2/8/2017	4/10/2017	NRTF	N/A	16
DL35163	Plastic Surgery	2/8/2017	4/10/2017	NRTF	N/A	16
DL37080	MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease	2/8/2017	4/10/2017	NRTF	N/A	16
DL37101	MolDX: Comprehensive Genomic Profiling to Guide Treatment in Patients with Advanced Primary Peritoneal, Fallopian Tube and Ovarian Cancer	2/8/2017	4/10/2017	NRTF	N/A	16
DL37114	Visual Electrophysiology Testing	2/8/2017	4/10/2017	NRTF	N/A	16
DL37105	MolDX: Comprehensive Genomic Profiling to Guide Treatment in Patients with Metastatic Colorectal Cancer	2/8/2017	4/10/2017	NRTF	N/A	16
DL37070	MolDX: DecisionDx-UM (Uveal Melanoma)	2/8/2017	4/10/2017	NRTF	N/A	16
DL37109	MolDX: Comprehensive Genomic Profiling to Guide Treatment in Patients with Metastatic Melanoma	2/8/2017	4/10/2017	NRTF	N/A	16
DL36704	MolDX- CDD: ProMark Risk Score	6/2/2016	8/8/2016	RTF	N/A	221
DL36886	MolDX-CDD: Percepta© Bronchial Genomic Classifier	10/6/2016	12/15/2016	RTF	N/A	92
DL34218	Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma	10/6/2016	12/15/2016	RTF	N/A	92
DL34211	Trigger Point Injections	10/6/2016	12/15/2016	RTF	N/A	92
DL36882	MolDX: APC and MUTYH Gene Testing	10/6/2016	12/15/2016	RTF	N/A	92
DL36941	MolDX - CDD: Oncotype DX® Breast Cancer for DCIS (Genomic Health ™)	10/6/2016	12/30/2016	RTF	L	77

*NRTF _ Not released to final.   RTF_ Released to final

MolDX Tier 2 pricing as of April 2017

http://www.palmettogba.com/palmetto/moldx.nsf/docscat/MolDx%20Website~MolDx~Browse%20By%20Topic~General~2016%20MoPath%20Tier%202%20Fee%20Schedule%20(M00005%20V9)


Captured 4/2017.

2016 MoPath Tier 2 Fee Schedule (M00005, V9)

As per Change Request (CR) 9465, CMS released the 2016 clinical laboratory fee schedule for tests reported with Tier 1 CPT codes. The table below lists the fees established for Tier 2 covered tests. Please note the genes are sorted by CPT code and then by alpha per gene. In Tier 2 codes multiple genes are listed under a single code. The required identifier assigned and submitted with each test enables MolDX to apply the appropriate fee for the specific test performed.  

HCPCS Code	Descriptor	Allowed
81400	ACE, idv	$82.58
81400	F13B, V34L	$64.52
81400	F2, 1199G>A	$70.20
81400	F5, HR2	$58.84
81400	F7,  R353Q	$64.52
81400	FGB,  -455G>A	$70.20
81400	HPA, antigen ea	$46.46
81400	IL28B, rs12979860	$55.23
81400	SERPINE1, 4G	$58.84
81401	ABL1, T315I	$153.01
81401	CYFB_MYH11, cv	$138.82
81401	CCND1_IGH, ta majbp qual qual	$93.94
81401	E2A_PBX1, ta qual quan,	$105.30
81401	EML4_ALK, ta or ia	$128.48
81401	ETV6_RUNX1, ta qual quan	$90.31
81401	EWSR1_ERG, ta qual quan	$151.42
81401	EWSR1_FLI1, ta qual quan	$162.85
81401	EWSR1_WT1, ta qual quan	$203.84
81401	F11, cv	$75.88
81401	FIP1L1_PDGFR, qual quan	$90.82
81401	FOXO1_PAX3, ta, qual quan	$120.75
81401	FOXO1_PAX7, ta, qual quan	$120.75
81401	IGH/BCL2, sbp	$123.36
81401	MUTYH, cv	$105.81
81401	PAX8_PPARG, ta	$54.19
81401	RUNX1_RUNX1T1, ta qual quan	$106.05
81401	TPMT, cv	$111.61
81401	TYMS, trv	$169.10
81401	VWF, cv (2N)	$278.18
81402	IGH_BCL2 majbp & mcr bp	$123.36
81402	KIT, cv	$98.13
81403	CEBPA, fgs	$235.54
81403	EPCAM, kfv	$93.94
81403	F8, intron 1 and 22a	$81.05
81403	IDH1, exon 4	$67.70
81403	IDH1_ IDH2, exon 4 panel	135.40
81403	IDH2, exon 4	$67.70
81403	JAK2, exon 12 and 13	$109.14
81403	MUTYH, kfv	$93.94
81403	RET, kfv	$93.94
81403	VHL , dup_del	$83.60
81403	VWF, tsa	$300.03
81404	CDKN2A, fgs	$373.14
81404	KIT, tga	$213.47
81404	NRAS, exon 1, 2	$148.04
81404	PDGFRA, tsa	$111.44
81404	PRSS1, fgs	$248.76
81404	RET, cv	$94.97
81404	VHL, fgs	$639.96
81405	MEN1, fgs	$426.32
81405	RET, tsa	$379.47
81405	VWF, tsa 2N	$278.18
81406	RET, fgs	$384.51