Effective for dates of service on or after April 1, 2019, CPT code 81455 (targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, interrogation for sequence variants and copy number variants or rearrangements, if performed) is a Medi-Cal benefit. An approved Treatment Authorization Request (TAR) is required for reimbursement. A TAR approval requires documentation of the following criteria:
- The patient has either recurrent, relapsed, refractory, metastatic or advanced stages III or IV cancer, and
- The patient either has not been previously tested using the same Next Generation Sequencing (NGS) test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician, and
- The decision for additional cancer treatment is contingent on the test results.
Modifiers 33, 90 and 99 are all allowable. CPT code 81455 is billable once in a lifetime. The frequency limitation may be overridden with a valid TAR.