Blue Cross and Blue Shield of Montana (BCBSMT) considers “Systems Pathology” tests that include cellular and biologic features of a tumor are considered experimental, investigational and unproven including use in predicting risk of recurrence in patients with prostate cancer.
Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.
There is no specific CPT code for systems pathology tests. The Prostate PX+ test and the Post-op Px test may possibly be billed as some combination of one or more of the following codes 88313, 88323, 88347, and/or an unlisted code such as 88399.
It is possible that code 99090, may be used instead of the unlisted code.
This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.
The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. BCBSMT recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.
When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.