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Medical & Coding Policies
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Out-of-State & Non-Network
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DESCRIPTIONCA-125 is a high molecular weight protein antigen that is commonly elevated in patients with known ovarian cancer. CA-125 may also be elevated in other gynecologic malignancies, such as endometrial cancer, although the association is not as consistent as that with ovarian cancer. CA-125 has been widely used as a technique to monitor patients with known ovarian cancer or other gynecologic malignancies that, in individual patients, are associated with elevated levels of CA-125. Frequently, a rising CA-125 will be the initial signal of recurrent disease.CA-125 has also been investigated as a possible screening tool for ovarian cancer, both in the general population and in patients considered at high risk of ovarian cancer. Levels of CA-125 may also be elevated in nonmalignant conditions, including pregnancy, endometriosis, pelvic inflammatory disease, benign ovarian masses, and without any identifiable cause. Other serum tumor markers are addressed in the Serum Tumor Markers policy. See separate policy for Urinary Tumor Markers for Bladder Cancer.
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POLICYMeasurements of CA-125 may be considered medically necessary in patients with symptoms suggestive of ovarian cancer or in those with known ovarian cancer.Measurement of CA-125 may be considered medically necessary in individual patients with other gynecologic malignancies, such as endometrial cancer, in whom baseline level of CA-125 have been shown to be elevated. Measurement of CA-125 is considered investigational in asymptomatic patients as a screening technique for ovarian cancer.
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POLICY EXCEPTIONSNone
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POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY6/28/2007: Policy added. CA-125 was previously addressed in the Serum Tumor Markers policy8/10/2007: Code reference section updated. Added ICD-9 codes 180.0, 198.82, 236.0, 236.1, 236.3, 789.39, and V10.43. 04/14/2010: Code reference section updated. Added ICD-9 diagnosis codes: 158.0, 158.8, 158.9, 184.8, 197.6, 218.0 - 218.9, 233.30, 233.39, 338.3, 789.30, 795.89, V10.41, V10.42 and V10.44. Also added the following verbiage: "*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section." 11/17/2010: Added ICD-9 codes 789.33 and 789.34 to the Covered Codes table. 12/08/2011: Added ICD-9 code 620.2 to the Covered Codes table. 12/21/2012: Policy reviewed; policy statement unchanged. Added the following new 2013 CPT codes to the Code Reference section: 81500 and 81503. 02/20/2013: Deleted CPT codes 81500 and 81503 from the Code Reference section as these are addressed in the Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses medical policy.
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SOURCE(S)Blue Cross Blue Shield Association Policy # 2.04.27
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CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. Covered Codes
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