BCBS Avalon Policies « The Pathology Laboratory

Test Number	Test Name	CPT Code(s)	BCBS Avalon Policy	Frequency Applies
8700	VITAMIN D	82306	G2005 Diagnosis codes G2005 BCBS Avalon policy	YES
2036	FERRITIN	82728	G2011 Diagnosis codes G2011 BCBS Avalon policy
3126	IRON	83540	G2011 Diagnosis codes G2011 BCBS Avalon policy
3128	IRON BINDING CAPACITY	83550	G2011 Diagnosis codes G2011 BCBS Avalon policy
3798	IRON AND TIBC	83540, 83550	G2011 Diagnosis codes G2011 BCBS Avalon policy
3796	IRON, TIBC, %TRANSFERRIN SATURATION	83540, 83550	G2011 Diagnosis codes G2011 BCBS Avalon policy
2048	TESTOSTERONE TOTAL	84403	G2013 Diagnosis codes G2013 BCBS Avalon policy
3042	ALBUMIN	82040	G2013 Diagnosis codes G2013 BCBS Avalon policy
3302	SEX HORMONE BINDING GLOBULIN (SHBG)	84270	G2013 Diagnosis codes G2013 BCBS Avalon policy
3303	FREE TESTOSTERONE	84402	G2013 Diagnosis codes G2013 BCBS Avalon policy
3304	BIOAVAILABLE & TOTAL TESTO + SHBG	84403, 84270, 84402	G2013 Diagnosis codes G2013 BCBS Avalon policy
3309	TESTOSTERONE FREE AND TOTAL + SHBG	84403, 84270, 84402	G2013 Diagnosis codes G2013 BCBS Avalon policy
3306	TESTOSTERONE FREE BIOAVAILABLE & TOTAL	84403, 84270, 84402	G2013 Diagnosis codes G2013 BCBS Avalon policy
8401	DNA AUTOANTIBODIES, DOUBLESTRANDED(CRITHIDIA)	86225	G2022 Diagnosis codes G2022 BCBS Avalon policy
8402	RNP/SM IGG	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8403	SS-A IGG AUTOAB	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8404	SS-B IGG AUTOAB	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8405	SM (SMITH) IGG AUTOAB	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8406	SCL-70	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8407	ANA PROFILE	86225, 86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8408	JO-1 AUTOAB	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8416	SSA/SSB IGG	86235	G2022 Diagnosis codes G2022 BCBS Avalon policy
8600	ANA IFA REFLEX TO PATTERN/TITER	86038	G2022 Diagnosis codes G2022 BCBS Avalon policy
8601	ANA TITER	86039	G2022 Diagnosis codes G2022 BCBS Avalon policy
8603	ANA IFA W/REFLEX TO TITER/PATTERN/PROFILE	86038	G2022 Diagnosis codes G2022 BCBS Avalon policy
8604	ANA TITER/PATTERN BY IFA	86039	G2022 Diagnosis codes G2022 BCBS Avalon policy
9100, 9300 AND 9400 SERIES	ALLERGENS (SPECIFIC IGE)	86003	G2031 Diagnosis codes G2031 BCBS Avalon policy	YES
9415, 9414, 9179	ALLERGEN COMPONENTS	86008	G2031 Diagnosis codes G2031 BCBS Avalon policy	YES
2026	IGE	82785	G2031 Diagnosis codes G2031 BCBS Avalon policy
3778	IMMUNOGLOBULINS	82784	G2031 Diagnosis codes G2031 BCBS Avalon policy
9200	CELIAC TTG IGA	83516	G2031 Diagnosis codes G2031 BCBS Avalon policy
9201	CELIAC TTG IGG	83516	G2031 Diagnosis code G2031 BCBS Avalon policy
9202	CELIAC DEAMIDATED GLIADIN IGA	83516	G2031 Diagnosis codes G2031 BCBS Avalon policy
9203	CELIAC DEAMIDATED GLIADIN IGG	83516	G2031 Diagnosis codes G2031 BCBS Avalon policy
9207	CELIAC COMPREHENSIVE PROFILE	82784, 83516	G2031 Diagnosis codes G2031 BCBS Avalon policy
9208	CELIAC TTG IGA/ TOTAL IGA PROFILE	82784, 83516	G2031 Diagnosis codes G2031 BCBS Avalon policy
8640	HEPATITIS C ANTIBODY	86803	G2036 Diagnosis codes G2157 Diagnosis codes G2036 BCBS Avalon policy G2157 BCBS Avalon policy	YES
2004	FREE T3	84481	G2045 Diagnosis codes G2045 BCBS Avalon policy
2050	TSH	84443	G2045 Diagnosis codes G2045 BCBS Avalon policy
3075	FREE T4 (THYROXINE)	84439	G2045 Diagnosis codes G2045 BCBS Avalon policy
3076	T- UPTAKE	84479	G2045 Diagnosis codes G2045 BCBS Avalon policy
3078	T4, TOTAL	84436	G2045 Diagnosis codes G2045 BCBS Avalon policy
3081	T3, TOTAL	84480	G2045 Diagnosis codes G2045 BCBS Avalon policy
3083	THYROID PEROXIDASE ANTIBODY (TPO)	86376	G2045 Diagnosis codes G2045 BCBS Avalon policy
3824	THYROID PANEL (T7)	84479, 84436	G2045 Diagnosis codes G2045 BCBS Avalon policy
3825P	THYROID PANEL II (WITH TSH)	84443, 84479, 84436	G2045 Diagnosis codes G2045 BCBS Avalon policy
3992	CRP	86140	G2155 Diagnosis codes G2155 BCBS Avalon policy
4098	SED RATE (WESTERGREN)	85652	G2155 Diagnosis codes G2155 BCBS Avalon policy
3024	CREATININE	82565	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
3755P	CREATININE CLEARANCE PANEL	82575	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
2038	HCG QUANTITATIVE	84702	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
2028	HCG QUALITATIVE	84703	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
6028	RPR	86592	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
6030	RPR TITER	86593	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8701	HSV-1 IgG	86695	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8702	HSV-2 IgG	86696	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8561	HEPATITIS B CORE ANTIBODY (IGM)	86705	G2157 Diagnosis codes G2036 Diagnosis codes G2157 BCBS Avalon policy G2036 BCBS Avalon policy	YES
8620	HEPATITIS B SURFACE ANTIBODY	86706	G2157 Diagnosis codes G2036 Diagnosis codes G2157 BCBS Avalon policy G2036 BCBS Avalon policy	YES
8703	SYPHILIS (TREPONEMA PALLIDIUM) ANTIBODY	86780	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8024	MRSA (MSSA) SCREENING CULTURE	87081	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8240	GC CULTURE	87081	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8520	HEPATITIS B SURFACE AG (HBsAg)	87340	G2157 Diagnosis codes G2036 Diagnosis codes G2157 BCBS Avalon policy G2036 BCBS Avalon policy	YES
8333	CHLAMYDIA (AMPLIFIED)	87491	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8400	CHLAMYDIA AND GONORRHEA AMP.	87491, 87591	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
8290	HSV 1/2 DNA AMPLIFIED	87529	G2157 Diagnosis code G2157 BCBS Avalon policy	YES
8335	GONORRHEA (AMPLIFIED)	87591	G2157 Diagnosis codes G2157 BCBS Avalon policy	YES
NA	PAP and HPV TESTING	87623, 87624, 87625, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, 0500T, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, G0476, P3000, P3001, Q0091	G2002 Diagnosis codes G2002 BCBS Avalon policy	YES
2021	PSA	84153	G2008 Diagnosis codes G2008 BCBS Avalon policy	YES
2168	GLUCOSE AND INSULIN 2 HOUR TOLERANCE	82951, 82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3010	HEMOGLOBIN A1C	83036	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3021	GLUCOSE (ADDITIONAL SPECIMEN)	82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3770	GLUCOSE TOLERANCE (2HR)	82951	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3772	GLUCOSE TOLERANCE (3HR)	82951, 82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3774	GLUCOSE TOLERANCE (4 HR)	82951, 82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3776	GLUCOSE TOLERANCE (5 HR)	82951, 82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3791	GLUCOSE TOLERANCE (3 HR WITH 1/2 HR INTERVALS)	82951, 82952	G2006 Diagnosis codes G2006 BCBS Avalon policy	YES
3785	LIPID II PROFILE	80061	G2050 Diagnosis codes G2050 BCBS Avalon policy	YES
3050	CHOLESTEROL	82465	G2050 Diagnosis codes G2050 BCBS Avalon policy	YES
3052	TRIGLYCERIDES	84478	G2050 Diagnosis codes G2050 BCBS Avalon policy	YES
3043	CRP HIGHLY SENSITIVE (CARDIO)	86141	G2050 Diagnosis codes G2050 BCBS Avalon policy	YES
8280	GROUP B STREP (MOLECULAR)	87081, 87150	G2157 Diagnosis codes G2157 BCBS Avalon policy
2034	ESTRADIOL (E2)	82670	G2013 Diagnosis codes G2013 BCBS Avalon policy