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CMS Transmittals

CodeMap® LCD-L36715


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LCD for BRCA1 and BRCA2 Genetic Testing (L36715)
See related Articles:
A56542-Billing and Coding: BRCA1 and BRCA2 Genetic Testing

Contractor Information

Contractor Name: Novitas Solutions, Inc. - Full list of policies of this Medicare Contractor

Contractor Number: 07101

Contractor Type: MAC A

LCD Information

LCD ID Number: L36715 Status: A-Approved

LCD Title: BRCA1 and BRCA2 Genetic Testing

Geographic Jurisdiction: Arkansas Other Jurisdictions

Original Determination Effective Date: 12/01/2016

Original Determination Ending Date:

Revision Effective Date: 12/10/2020

Revision End Date:

CMS National Coverage Policy:

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for BRCA1 and BRCA2 genetic testing services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify, or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for BRCA1 and BRCA2 genetic testing services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 2, Section 90.2 Next Generation Sequencing (NGS) for Patients with Advanced Cancer
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual
    • Chapter 16, Section 50.5 Jurisdiction of Laboratory Claims, Section 60.1.2 Independent Laboratory Specimen Drawing and Section 60.2: Travel Allowance
    • Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes
  • CMS IOM, Publication 100-08, Medicare Benefit Policy Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

  • Code of Federal Regulations (CFR) Title 42 Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

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All information on this web site is compiled directly from information obtained from the Center for Medicare and Medicaid Services (CMS) and from its Contractors.

CodeMap® has made every reasonable effort to ensure the accuracy of the information contained on this web site. However, the ultimate responsibility for correct coding and claims submission lies with the provider of services. CodeMap® makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free or that the use of this information will result in Medicare coverage and subsequent payment of claims. Final coverage and payment of claims are subject to many factors exclusively controlled by CMS and its contractors.

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06/13/2024 05:44:14

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