BlueCross BlueShield of Tennessee Medical Policy Manual

Pathology

• Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

• Analysis of Proteomic Patterns in Serum to Identify Ovarian Cancer

• Array Comparative Genomic Hybridization (aCGH) for the Genetic Evaluation of Individuals with Developmental Delay/Mental Retardation

• Biochemical Markers for Alzheimer’s Disease

• Cervical Cancer Screening Technologies (Pap/HPV/Speculoscopy/Cervicography)

• Collagen Cross Links as Markers of Bone Turnover

• Cytochrome p450 Genotyping

• Cytologic Evaluation in Breast Cancer Risk Assessment

• Detection and Quantification of Circulating Tumor Cells in the Management of Individuals with Cancer

• Diagnostic Labwork for Erectile Dysfunction

• Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Individuals with Non-Small Cell Lung Cancer (NSCLC)

• Fecal Calprotectin Testing

• Fetal Fibronectin (fFN) to Predict Preterm Labor

• First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

• Gene Expression Profiling Assays as a Technique to Determine Prognosis for Managing Breast Cancer Treatment

• Gene Expression Testing for Coronary Artery Disease

• Gene-based Tests for Screening, Detection, and/or Management of Prostate Cancer

• Genetic Testing for Alzheimer's Disease

• Genetic Testing for BRCA1, BRCA2 or CHEK2 for Breast or Ovarian Cancer

• Genetic Testing for Congenital Cardiac Channelopathies

• Genetic Testing for Cutaneous Malignant Melanoma

• Genetic Testing for Cystic Fibrosis

• Genetic Testing for Helicobacter pylori Treatment

• Genetic Testing for HER-2

• Genetic Testing for Inherited Susceptibility to Colorectal Cancer

• Genetic Testing for Medullary Thyroid Carcinoma

• Genetic Testing for Tamoxifen Treatment

• Genetic Testing for Warfarin Dose

• Genotyping for Chronic Hepatitis C

• High Sensitivity C-Reactive Protein (hs-CRP) Testing for Cardiovascular Disease (CVD)

• Homocysteine Testing in the Screening, Diagnosis, and Management of Dyslipidemia and Cardiovascular Disease

• Immunochemical Fecal Occult Blood Tests

• In Vitro Chemosensitivity and Chemoresistance Assays

• In Vitro Particle Size Measurement for Screening Hypersensitivity Reactions to Foods and Chemicals

• Intracellular Micronutrient Analysis

• KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

• Laboratory Tests for Heart Transplant Rejection

• Leukocyte Histamine Release Test (LHRT)

• Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease

• Lymphocytic Mitogen Response Assay for the Diagnosis of Vitamin, Mineral, and Antioxidant Functional Deficiencies

• Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk

• Measurement of Serum Intermediate Density Lipoproteins (Remnant Lipoproteins)

• Microalbumin Screening for Diabetic Nephropathy

• Microarray-based Gene Expression Testing for Cancers of Unknown Primary

• Molecular Anatomic Pathology Testing

• Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer

• Non-BRCA Breast Cancer Risk Assessment

• Ovarian Cancer Tumor Markers

• Platelet Rich Plasma as a Treatment for Wound Healing or Other Conditions

• Prostate Specific Antigen (PSA)

• Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses

• Saliva Testing for Hormone Levels

• Serologic Diagnosis of Celiac Disease

• Serum Antibodies for the Diagnosis and Management of Inflammatory Bowel Disease: ANCA for Ulcerative Colitis and ASCA for Crohn's Disease

• Serum Biomarker Human Epididymis Protein 4 (HE4)

• Serum Holotranscobalamin as a Marker of Vitamin B12 (Cobalamin) Status

• Serum Tumor Markers for Breast Malignancies

• Serum Tumor Markers for Gastrointestinal Cancer

• Specific IgE In Vitro Tests (RAST, MAST & FAST)

• Urine-Based HIV-1 Testing System

• Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer

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