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Clinical Criteria for Lab Testing

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​View or download clinical criteria by lab testing type.

  • 0172U myChoice CDX
  • 81401- (Molecular Pathology Procedure Level 2)
  • 81420, 81422, 81479, 81507- (NIPTS)
  • 81415, 81416, 81417- (Whole Exome Sequencing)​
  • 81425, 81426, 81427 (Whole Genomic​ Sequencing)​
  • 81445, 81450, 814​55- (Targeted Genomic Sequencing)
  • ​​81528- (Oncology, Colon Cancer Screening/Cologuard)

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Related Webpages

  • Clinical Criteria for Laboratory Testing
  • Clinical Criteria for Drugs and Injectables Requiring Preauthorization
  • Preauthorization Information

Related Documents

  • BioMarkers for Companion Diagnostic Testing & Target Drug Therapy - Clinical Criteria
  • Colon Cancer Screening Updated 2021
  • Lung Cancer Screening Updates 2022 
  • Out-of-State Inpatient Admissions Criteria
  • Professional Services Codes Requiring Preauthorization
  • Gender-Affirming Treatments- Expanded Coverage​
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