Tuesday, February 28, 2017

CPT 86152 and 86153 - CTC ASSAYS

Coverage Indications, Limitations, and/or Medical Necessity


This LCD addresses limited coverage for the CellSearch ® Circulating Tumor Cell (CTC) (Veridex, LLC) assay. All other methods for CTC detection, including PCR (RTPCR) assays, are non-covered.

CTCs represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy is an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer.

The assay is reported as a numerical result where five or more cells per 7.5 ml of whole blood predicts worse prognosis in patients with known recurrent breast and prostate cancer, and three or more cells are predictive of shorter Progression Free Survival (PFS) and Overall Survival (OS) in metastatic colorectal cancer.

CTC is indicated for an established diagnosis of:
Breast cancer;
Colorectal cancer;
Prostate cancer.


All methods for CTC enrichment/detection other than the CellSearch ® CTC assay, including PCR (RT-PCR) assays, are non-covered as they are considered investigational.

CTC testing will be limited to metastatic breast, colorectal and prostate cancer. CTC testing for all other malignant diagnoses will be denied as not reasonable and necessary.

All assays for CTC are non-covered for routine screening or prognosis.

No further CTC testing would be expected after the transition to palliative/hospice care.

Baseline – limited to once prior to initiation of tumor-type specific chemotherapy.
During chemotherapy treatment – may be performed once during chemotherapy.
Following chemotherapy treatment – may be repeated at end of chemotherapy.
Surveillance with no chemotherapy treatments - may be repeated each year.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.



Group 1 Paragraph: N/A

Group 1 Codes:
86152 Cell enumeration & id
86153 Cell enumeration phys interp

ICD-10 Codes that Support Medical Necessity


C18.0 - C21.8 - Opens in a new window Malignant neoplasm of cecum - Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C50.011 - C50.929 - Opens in a new window Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of unspecified site of unspecified male breast
C61 Malignant neoplasm of prostate
Showing 1 to 3 of 3 entries in Group 1
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