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The following is a list of tests which UCSF is responsible for verifying Medical Necessity. Click on a test name to see a list of ICD9 codes that meet the guidelines for Medical Necessity

To search for a specific ICD9 code, try the following web site: http://icd9data.com/

CMS Lab NCD information is available for download at the following web site: http://www.cms.hhs.gov/CoverageGenInfo/04_LabNCDs.asp#TopOfPage

CMS Lab LCD information for Palmetto GBA Part A is available for download at the following web site: http://www.cms.hhs.gov/mcd/results_index.asp?from2=results_index.asp&contractor=171&from='lmrpcontractor'&retired=&name=Palmetto%20GBA%20(01101,%20MAC%20-%20Part%20A)&letter_range=4&

National Coverage Determination (NCD)

Acute Hepatitis Panel (only applies if all test below are ordered on the same date of service)

• Hepatitis A, IgM Antibody
• Hepatitis B Core Antibody, IgM
• Hepatitis B Surface Antigen
• Hepatitis C Antibody

Alpha-fetoprotein, serum

Blood Counts

• Blood Smear Morphology
• Complete Blood Count (includes Platelet Count)
• Complete Blood Count with 5-part Differential
• Hemoglobin
• Hematocrit, automated
• Nucleated red cells
• Platelet Count

Blood Glucose

• Glucose Tolerance Test, Pregnancy
• Glucose, Body fluid
• Glucose, fasting
• Glucose, non-fasting

Carcinoembryonic Antigen

Collagen Crosslinks

Digoxin

Fecal Occult Blood Test

Gamma Glutamyl Transferase

Glycated Hemoglobin/Glycated Protein

• Fructosamine
• Hemoglobin A1c

HIV Testing (Prognosis)

• HIV-1 DNA, Qualitative, by PCR
• HIV-1 RNA, Quantitative, bDNA
• HIV-1 RNA, Quantitative, by PCR

HIV Testing (Diagnosis)

• HIV Antibody Screen
• HIV Antibody Screen Confirmation

Human Chorionic Gonadotropin

• Human Chorionic Gonadotropin for Pregnancy, serum
• Human Chorionic Gonadotropin for Tumor, serum

Lipids Testing

• Cholesterol, HDL
• Cholesterol, Total
• Triglycerides, Body fluid
• Triglycerides, serum
• VAP TM Cholesterol Test

Prostate Specific Antigen

• Prostate Specific Antigen, Total

Prothrombin Time (PT)

Partial Thromboplastin Time (PTT)

Serum Iron Studies

• Iron, liver
• Iron, serum
• Iron, Transferrin and % Transferrin Saturation
• Iron, urine
• Transferrin, beta-1-

Thyroid Testing

• Free T3, Adult
• Free T3, Pediatric
• Free T4
• Free T4 (by dialysis)
• T3, Reverse
• T3, Total
• T4, Total
• Thyroid Stimulating Hormone

Tumor Antigen by Immunoassay CA 19-9

Tumor Antigen by Immunoassay CA 125

Tumor Antigen by Immunoassay CA 15-3/CA 27.29

Urine Culture, Bacterial

Local Coverage Determination (LCD)

Acid Phosphatase

• Acid Phosphatase, Total
• Prostatic Acid Phosphatase (note: Prostatic Acid Phosphatase is not covered for any indication)

B-type Natriuretic Peptide

Erythrocyte Sedimentation Rate - Retired, no longer in effect

High Sensitivity C-Reactive Protein

Homocysteine Level, Serum

Serum Magnesium