Trofile Test Frequency Update

Effective for dates of service on or after June 1, 2009, the policy regarding Trofile test frequency limits when billing with CPT-4 code 87999 (unlisted microbiology procedure) has changed from administering the test only once in a recipient's lifetime to allowing subsequent tests with a required Treatment Authorization Request (TAR). The amended reimbursement policy for Trofile testing follows:

Initial Test

The first Trofile test will be reimbursed when providers document the following items:

  • The intention to treat or not to treat with a CCR5 antagonist drug is contingent upon test results; and,
  • The most recent anti-viral drug resistance test results showing that the virus is sensitive to at least one other anti-retroviral drug (other than a CCR5 antagonist); and,
  • At least one of the following clinical scenarios is present:
    • The recipient has evidence of anti-retroviral drug resistance; or,
    • The recipient has evidence of anti-retroviral drug intolerance; or,
    • There is a lack of recipient acceptance to reasonable alternatives resulting in the inability to fully suppress HIV.

Subsequent Tests

Additional Trofile tests require a TAR and the following items must be documented:

  • A previous Trofile test was performed including the test date and the results show that the recipient has a CCR5 virus; and,
  • The recipient's previous Trofile test was not less than 90 days from the subsequent request; and,
  • The recipient has a clinical scenario such as, but not limited to, the following:
    • The treatment with CCR5 antagonist drug therapy was interrupted and the clinician wishes to reinstitute CCR5 antagonist drug therapy; or,
    • The recipient had a Trofile test performed previously that showed that the recipient had the CCR5 virus, but CCR5 antagonist drug therapy was never initiated.

SOURCE: Source
INDUSTRY NEWS TAGS: California Medi-Cal

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