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CMS Transmittals

National Coverage Determination
Procedure Code: 8XXXX
CMS Policy Number: 190.25
Back to NCD List

Description: Alpha-fetoprotein (AFP) is a polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy.

AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms or metastases from those with hepatocellular carcinoma and, as a non-specific tumor associated antigen, serves in marking germ cell neoplasms of the testis, ovary, retro peritoneum, and mediastinum.

To review all requirements of this policy, please see: CMS NCD listing by Chapter

Covered ICD-10 Codes.

A52.74 Syphilis of liver and other viscera
B18.0 Chronic viral hepatitis B with delta-agent
B18.1 Chronic viral hepatitis B without delta-agent
B18.2 Chronic viral hepatitis C
B66.1 Clonorchiasis
B66.3 Fascioliasis
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malig neoplasm of liver, not specified as primary or sec
C38.1 Malignant neoplasm of anterior mediastinum
C38.2 Malignant neoplasm of posterior mediastinum
C38.3 Malignant neoplasm of mediastinum, part unspecified
C38.8 Malig neoplm of ovrlp sites of heart, mediastinum and pleura
C44.1321 Sebaceous cell carcinoma skin/ r upper eyelid, inc canthus
C44.1322 Sebaceous cell carcinoma skin/ right low eyelid, inc canthus
C44.1391 Sebaceous cell carcinoma skin/ left upr eyelid, inc canthus
C44.1392 Sebaceous cell carcinoma skin/ left low eyelid, inc canthus
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.9 Malignant neoplasm of unspecified ovary
C62.00 Malignant neoplasm of unspecified undescended testis
C62.01 Malignant neoplasm of undescended right testis
C62.02 Malignant neoplasm of undescended left testis
C62.10 Malignant neoplasm of unspecified descended testis
C62.11 Malignant neoplasm of descended right testis
C62.12 Malignant neoplasm of descended left testis
C62.90 Malig neoplasm of unsp testis, unsp descended or undescended
C62.91 Malig neoplm of right testis, unsp descended or undescended
C62.92 Malig neoplasm of left testis, unsp descended or undescended
C78.1 Secondary malignant neoplasm of mediastinum
C78.7 Secondary malig neoplasm of liver and intrahepatic bile duct
C79.60 Secondary malignant neoplasm of unspecified ovary
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.82 Secondary malignant neoplasm of genital organs
C7A.00 Malignant carcinoid tumor of unspecified site
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.094 Malignant carcinoid tumor of the foregut, unspecified
C7A.095 Malignant carcinoid tumor of the midgut, unspecified
C7A.096 Malignant carcinoid tumor of the hindgut, unspecified
C7A.098 Malignant carcinoid tumors of other sites
C7B.00 Secondary carcinoid tumors, unspecified site
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.1 Secondary Merkel cell carcinoma
C7B.8 Other secondary neuroendocrine tumors
D13.4 Benign neoplasm of liver
D13.5 Benign neoplasm of extrahepatic bile ducts
D37.6 Neoplasm of uncertain behavior of liver, GB & bile duct
D64.0 Hereditary sideroblastic anemia
D64.1 Secondary sideroblastic anemia due to disease
D64.2 Secondary sideroblastic anemia due to drugs and toxins
D64.3 Other sideroblastic anemias
D81.810 Biotinidase deficiency
D84.1 Defects in the complement system
E78.2 Mixed hyperlipidemia
E83.00 Disorder of copper metabolism, unspecified
E83.01 Wilson's disease
E83.09 Other disorders of copper metabolism
E83.10 Disorder of iron metabolism, unspecified
E83.110 Hereditary hemochromatosis
E83.111 Hemochromatosis due to repeated red blood cell transfusions
E83.118 Other hemochromatosis
E83.119 Hemochromatosis, unspecified
E83.19 Other disorders of iron metabolism
E84.19 Cystic fibrosis with other intestinal manifestations
E84.9 Cystic fibrosis, unspecified
E88.01 Alpha-1-antitrypsin deficiency
E88.02 Plasminogen deficiency
G89.3 Neoplasm related pain (acute) (chronic)
I25.84 Coronary atherosclerosis due to calcified coronary lesion
I74.01 Saddle embolus of abdominal aorta
I74.09 Other arterial embolism and thrombosis of abdominal aorta
I74.10 Embolism and thrombosis of unspecified parts of aorta
I74.19 Embolism and thrombosis of other parts of aorta
J98.59 Other diseases of mediastinum, not elsewhere classified
K70.2 Alcoholic fibrosis and sclerosis of liver
K70.30 Alcoholic cirrhosis of liver without ascites
K70.31 Alcoholic cirrhosis of liver with ascites
K73.0 Chronic persistent hepatitis, not elsewhere classified
K73.1 Chronic lobular hepatitis, not elsewhere classified
K73.2 Chronic active hepatitis, not elsewhere classified
K73.8 Other chronic hepatitis, not elsewhere classified
K73.9 Chronic hepatitis, unspecified
K74.0 Hepatic fibrosis
K74.60 Unspecified cirrhosis of liver
K74.69 Other cirrhosis of liver
K75.4 Autoimmune hepatitis
K76.81 Hepatopulmonary syndrome
N44.1 Cyst of tunica albuginea testis
N44.2 Benign cyst of testis
N44.8 Other noninflammatory disorders of the testis
N50.3 Cyst of epididymis
N50.811 Right testicular pain
N50.812 Left testicular pain
N50.819 Testicular pain, unspecified
N50.82 Scrotal pain
N50.89 Other specified disorders of the male genital organs
N53.12 Painful ejaculation
N53.8 Other male sexual dysfunction
N53.9 Unspecified male sexual dysfunction
Q53.111 Unilateral intraabdominal testis
Q53.112 Unilateral inguinal testis
Q53.13 Unilateral high scrotal testis
Q53.211 Bilateral intraabdominal testes
Q53.212 Bilateral inguinal testes
Q53.23 Bilateral high scrotal testes
R39.83 Unilateral non-palpable testicle
R39.84 Bilateral non-palpable testicles
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
R93.1 Abnormal findings on dx imaging of heart and cor circ
R93.2 Abnormal findings on dx imaging of liver and biliary tract
R93.5 Abn findings on dx imaging of abd regions, inc retroperiton
R93.811 Abnormal radiologic findings on dx imaging of right testicle
R93.812 Abnormal radiologic findings on dx imaging of left testicle
R93.813 Abnormal radlgc findings on dx imaging of testicles, bi
R93.819 Abnormal radiologic findings on dx imaging of unsp testicle
R93.89 Abnormal findings on dx imaging of oth body structures
R97.8 Other abnormal tumor markers
Z17.0 Estrogen receptor positive status [ER+]
Z17.1 Estrogen receptor negative status [ER-]
Z85.05 Personal history of malignant neoplasm of liver
Z85.43 Personal history of malignant neoplasm of ovary
Z85.47 Personal history of malignant neoplasm of testis

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