Medical Policies and Clinical Guidelines
Effective for dates of service on and after January 1, 2025, the following guidelines will apply to outpatient services for routine lab testing. These updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services. Visit the Carelon Clinical Guidelines and Pathways for further details here.
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Services that are indicated if medical necessity criteria is met
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- Human Chorionic Gonadotropin
- Tumor Antigen by Immunoassay CA 125
- Gamma Glutamyl Transferase
- Glycated Hemoglobin/Glycated Protein
- Blood Glucose Testing
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- Alpha-fetoprotein
- Prostate Specific Antigen
- Serum Iron Studies
- Urine Culture
- Thyroid Testing
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Services that are always considered not medically necessary for any indication
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- In vitro chemosensitivity and In vitro chemoresistance assays
- Selected Protein Biomarker Algorithmic Assays
- Detection of Circulating Tumor Cells
- Proprietary Algorithms for Liver Fibrosis
- Immune Cell Function Assay
- Blood-based Biomarker Tests for Multiple Sclerosis
- Rupture of Membranes Testing in Pregnancy
- Advanced Lipoprotein Testing
- Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- Serological Antibody Testing for Helicobacter Pylori
- Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
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- Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
- Combined Pathogen Identification and Drug Resistance Testing
- Serum Biomarker Tests for Risk of Preeclampsia
- Machine Learning Derived Probability Score for Rapid Kidney Function Decline
- Selected Tests for the Evaluation and Management of Infertility
- Testing for Biochemical Markers for Alzheimer’s Disease
- Pain Management Biomarker Analysis
- Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
- Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
- Respiratory Viral Panel Testing in the Outpatient Setting
- Red Blood Cell Folic Acid Testing
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