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BCBS Avalon Policies

Find your test below to see which BCBS Avalon policy applies, the diagnosis codes that support medical necessity, and whether frequency limits apply. Use the search box to filter by test number, test name, or CPT code.
Test NumberTest NameCPT Code(s)Diagnosis CodesPolicyFrequency Applies
2036FERRITIN82728G2011 Diagnosis CodesG2011 Policy (link pending)
3126IRON83540G2011 Diagnosis CodesG2011 Policy (link pending)
3128IRON BINDING CAPACITY83550G2011 Diagnosis CodesG2011 Policy (link pending)
8700VITAMIN D82306G2005 Diagnosis CodesG2005 PolicyYES
3798IRON AND TIBC83540, 83550G2011 Diagnosis CodesG2011 Policy (link pending)
3796IRON, TIBC, %TRANSFERRIN SATURATION83540, 83550G2011 Diagnosis CodesG2011 Policy (link pending)
2048TESTOSTERONE TOTAL84403G2013 Diagnosis CodesG2013 Policy
3042ALBUMIN82040G2013 Diagnosis CodesG2013 Policy
3302SEX HORMONE BINDING GLOBULIN (SHBG)84270G2013 Diagnosis CodesG2013 Policy
3303FREE TESTOSTERONE84402G2013 Diagnosis CodesG2013 Policy
3304BIOAVAILABLE & TOTAL TESTO + SHBG84403, 84270, 84402G2013 Diagnosis CodesG2013 Policy
3309TESTOSTERONE FREE AND TOTAL + SHBG84403, 84270, 84402G2013 Diagnosis CodesG2013 Policy
3306TESTOSTERONE FREE BIOAVAILABLE & TOTAL84403, 84270, 84402G2013 Diagnosis CodesG2013 Policy
8401DNA AUTOANTIBODIES, DOUBLESTRANDED(CRITHIDIA)86225G2022 Diagnosis CodesG2022 Policy
8402RNP/SM IGG86235G2022 Diagnosis CodesG2022 Policy
8403SS-A IGG AUTOAB86235G2022 Diagnosis CodesG2022 Policy
8404SS-B IGG AUTOAB86235G2022 Diagnosis CodesG2022 Policy
8405SM (SMITH) IGG AUTOAB86235G2022 Diagnosis CodesG2022 Policy
8406SCL-7086235G2022 Diagnosis CodesG2022 Policy
8407ANA PROFILE86225, 86235G2022 Diagnosis CodesG2022 Policy
8408JO-1 AUTOAB86235G2022 Diagnosis CodesG2022 Policy
8416SSA/SSB IGG86235G2022 Diagnosis CodesG2022 Policy
8600ANA IFA REFLEX TO PATTERN/TITER86038G2022 Diagnosis CodesG2022 Policy
8601ANA TITER86039G2022 Diagnosis CodesG2022 Policy
8603ANA IFA W/REFLEX TO TITER/PATTERN/PROFILE86038G2022 Diagnosis CodesG2022 Policy
8604ANA TITER/PATTERN BY IFA86039G2022 Diagnosis CodesG2022 Policy
9100, 9300 AND 9400 SERIESALLERGENS (SPECIFIC IGE)86003G2031 Diagnosis CodesG2031 PolicyYES
9415, 9414, 9179ALLERGEN COMPONENTS86008G2031 Diagnosis CodesG2031 PolicyYES
2026IGE82785G2031 Diagnosis CodesG2031 Policy
3778IMMUNOGLOBULINS82784G2031 Diagnosis CodesG2031 Policy
9200CELIAC TTG IGA83516G2031 Diagnosis CodesG2031 Policy
9201CELIAC TTG IGG83516G2031 Diagnosis CodesG2031 Policy
9202CELIAC DEAMIDATED GLIADIN IGA83516G2031 Diagnosis CodesG2031 Policy
9203CELIAC DEAMIDATED GLIADIN IGG83516G2031 Diagnosis CodesG2031 Policy
9207CELIAC COMPREHENSIVE PROFILE82784, 83516G2031 Diagnosis CodesG2031 Policy
9208CELIAC TTG IGA/ TOTAL IGA PROFILE82784, 83516G2031 Diagnosis CodesG2031 Policy
2004FREE T384481G2045 Diagnosis CodesG2045 Policy
2050TSH84443G2045 Diagnosis CodesG2045 Policy
3075FREE T4 (THYROXINE)84439G2045 Diagnosis CodesG2045 Policy
3076T- UPTAKE84479G2045 Diagnosis CodesG2045 Policy
3078T4, TOTAL84436G2045 Diagnosis CodesG2045 Policy
3081T3, TOTAL84480G2045 Diagnosis CodesG2045 Policy
3083THYROID PEROXIDASE ANTIBODY (TPO)86376G2045 Diagnosis CodesG2045 Policy
3824THYROID PANEL (T7)84479, 84436G2045 Diagnosis CodesG2045 Policy
3825PTHYROID PANEL II (WITH TSH)84443, 84479, 84436G2045 Diagnosis CodesG2045 Policy
3992CRP86140G2155 Diagnosis CodesG2155 Policy
4098SED RATE (WESTERGREN)85652G2155 Diagnosis CodesG2155 Policy
8640HEPATITIS C ANTIBODY86803G2036 Diagnosis Codes
G2157 Diagnosis Codes		G2036 Policy
G2157 Policy		YES
NAPAP and HPV TESTING87623, 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, Q0091G2002 Diagnosis CodesG2002 PolicyYES
3024CREATININE82565G2157 Diagnosis CodesG2157 PolicyYES
3755PCREATININE CLEARANCE PANEL82575G2157 Diagnosis CodesG2157 PolicyYES
2038HCG QUANTITATIVE84702G2157 Diagnosis CodesG2157 PolicyYES
2028HCG QUALITATIVE84703G2157 Diagnosis CodesG2157 PolicyYES
6028RPR86592G2157 Diagnosis CodesG2157 PolicyYES
6030RPR TITER86593G2157 Diagnosis CodesG2157 PolicyYES
8701HSV-1 IgG86695G2157 Diagnosis CodesG2157 PolicyYES
8702HSV-2 IgG86696G2157 Diagnosis CodesG2157 PolicyYES
8561HEPATITIS B CORE ANTIBODY (IGM)86705G2157 Diagnosis Codes
G2036 Diagnosis Codes		G2157 Policy
G2036 Policy		YES
8620HEPATITIS B SURFACE ANTIBODY86706G2157 Diagnosis Codes
G2036 Diagnosis Codes		G2157 Policy
G2036 Policy		YES
8703SYPHILIS (TREPONEMA PALLIDIUM) ANTIBODY86780G2157 Diagnosis CodesG2157 PolicyYES
8024MRSA (MSSA) SCREENING CULTURE87081G2157 Diagnosis CodesG2157 PolicyYES
8240GC CULTURE87081G2157 Diagnosis CodesG2157 PolicyYES
8520HEPATITIS B SURFACE AG (HBsAg)87340G2157 Diagnosis Codes
G2036 Diagnosis Codes		G2157 Policy
G2036 Policy		YES
8333CHLAMYDIA (AMPLIFIED)87491G2157 Diagnosis CodesG2157 PolicyYES
8400CHLAMYDIA AND GONORRHEA AMP.87491, 87591G2157 Diagnosis CodesG2157 PolicyYES
8290HSV 1/2 DNA AMPLIFIED87529G2157 Diagnosis CodesG2157 PolicyYES
8335GONORRHEA (AMPLIFIED)87591G2157 Diagnosis CodesG2157 PolicyYES
2021PSA84153G2008 Diagnosis CodesG2008 PolicyYES
2168GLUCOSE AND INSULIN 2 HOUR TOLERANCE82951, 82952G2006 Diagnosis CodesG2006 PolicyYES
3010HEMOGLOBIN A1C83036G2006 Diagnosis CodesG2006 PolicyYES
3021GLUCOSE (ADDITIONAL SPECIMEN)82952G2006 Diagnosis CodesG2006 PolicyYES
3770GLUCOSE TOLERANCE (2HR)82951G2006 Diagnosis CodesG2006 PolicyYES
3772GLUCOSE TOLERANCE (3HR)82951, 82952G2006 Diagnosis CodesG2006 PolicyYES
3774GLUCOSE TOLERANCE (4 HR)82951, 82952G2006 Diagnosis CodesG2006 PolicyYES
3776GLUCOSE TOLERANCE (5 HR)82951, 82952G2006 Diagnosis CodesG2006 PolicyYES
3791GLUCOSE TOLERANCE (3 HR WITH 1/2 HR INTERVALS)82951, 82952G2006 Diagnosis CodesG2006 PolicyYES
3785LIPID II PROFILE80061G2050 Diagnosis CodesG2050 PolicyYES
3050CHOLESTEROL82465G2050 Diagnosis CodesG2050 PolicyYES
3052TRIGLYCERIDES84478G2050 Diagnosis CodesG2050 PolicyYES
3043CRP HIGHLY SENSITIVE (CARDIO)86141G2050 Diagnosis CodesG2050 PolicyYES
8280GROUP B STREP (MOLECULAR)87081, 87150G2157 Diagnosis CodesG2157 Policy
2034ESTRADIOL (E2)82670G2013 Diagnosis CodesG2013 Policy

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