Laboratory Benefit Management Program

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Policy Name Policy Number Effective Date Archived Documents
Allergen Testing CPCPLAB013 2/1/2023 N/A
ANA-ENA Testing CPCPLAB011 2/1/2023 N/A
Beta Hemolytic Streptococcus Testing CPCPLAB053 2/1/2023 N/A
Cardiac Biomarkers for Myocardial Infarction CPCPLAB046 2/1/2023 N/A
Cardiovascular Disease Risk Assessment CPCPLAB020 2/1/2023 N/A
Celiac Disease Testing CPCPLAB017 11/1/2022 N/A
Cervical Cancer Screening CPCPLAB002 2/1/2023 N/A
Diagnosis of Idiopathic Environmental Intolerance CPCPLAB023 11/1/2022 N/A
Diagnosis of Vaginitis CPCPLAB059 2/1/2023 N/A
Diagnostic Testing of Influenza CPCPLAB033 11/1/2022 N/A
Diagnostic Testing of Iron Homeostasis and Metabolism CPCPLAB008 11/1/2022 N/A
DNA Ploidy Cell Cycle Analysis CPCPLAB066 11/1/2022 N/A
Epithelial Cell Cytology in Breast Cancer Risk Assessment CPCPLAB024 11/1/2022 N/A
Erectile Dysfunction CPCPLAB041 2/1/2023 N/A
Evaluation of Dry Eyes CPCPLAB043 11/1/2022 N/A
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis CPCPLAB025 2/1/2023 N/A
Fecal Calprotectin Testing in Adults CPCPLAB026 11/1/2022 N/A
Flow Cytometry CPCPLAB001 2/1/2023 N/A
Folate Testing CPCPLAB048 2/1/2023 N/A
Gamma-glutamyl Transferase CPCPLAB056 11/1/2022 N/A
General Inflammation Testing CPCPLAB049 2/1/2023 N/A
Genetic Testing for Adolescent Idiopathic Scoliosis CPCPLAB060 11/1/2022 N/A
Helicobacter pylori Testing CPCPLAB018 2/1/2023 N/A
Hemoglobin A1c CPCPLAB004 2/1/2023 N/A
Hepatitis C CPCPLAB015 2/1/2023 N/A
Identification of Microorganisms Using Nucleic Acid Probes CPCPLAB063 2/1/2023 N/A
Immune Cell Function Assay CPCPLAB028 11/1/2022 N/A
Immunohistochemistry CPCPLAB069 11/1/2022 N/A
In Vitro Chemoresistance and Chemosensitive Assays CPCPLAB030 11/1/2022 N/A
Intracellular Micronutrient Analysis CPCPLAB029 11/1/2022 N/A
Laboratory Testing for Diagnosis of Inflammatory Bowel Disease CPCPLAB035 11/1/2022 N/A
Lyme Disease CPCPLAB044 11/1/2022 N/A
Measurement of Thromboxane Metabolites CPCPLAB031 11/1/2022 N/A
Nerve Fiber Density Testing CPCPLAB064 2/1/2023 N/A
Onychomycosis Testing CPCPLAB068 11/1/2022 N/A
Oral Screening Lesion Identification Systems CPCPLAB032 11/1/2022 N/A
Pancreatic Enzyme Testing for Acute Pancreatitis CPCPLAB047 2/1/2023 N/A
Parathyroid Hormone Phosphorous Calcium and Magnesium Testing CPCPLAB055 11/1/2022 N/A
Pathogen Panel Testing CPCPLAB045 11/1/2022 N/A
Pediatric Preventive Screening CPCPLAB016 2/1/2023 N/A
Plasma HIV-1 and HIV-2 RNA Quantification CPCPLAB065 11/1/2022 N/A
Prenatal Screening CPCPLAB014 2/1/2023 N/A
Prenatal Screening for Fetal Aneuploidy CPCPLAB022 11/1/2022 N/A
Pre-Operative Testing CPCPLAB012 2/1/2023 N/A
Prescription Medication and Illicit Drug Testing in the Output Setting CPCPLAB070 11/1/2022 N/A
Preventive Screening in Adults CPCPLAB007 11/1/2022 N/A
Prostate Biopsies CPCPLAB005 11/1/2022 N/A
Prostate Specific Antigen Testing CPCPLAB006 2/1/2023 N/A
Salivary Hormone Testing CPCPLAB034 11/1/2022 N/A
Serum Biomarker Testing for MS and Related Neuro Diseases CPCPLAB036 2/1/2023 N/A
ST2 Assay for Chronic Heart Failure CPCPLAB040 11/1/2022 N/A
Testing for Alpha-1 Antitrypsin Deficiency CPCPLAB061 11/1/2022 N/A
Testing for Diagnosis of Active or Latent TB CPCPLAB027 11/1/2022 N/A
Testing for Homocysteine Metabolism Related Conditions CPCPLAB067 11/1/2022 N/A
Testing for Mosquito or Tick Related Infections CPCPLAB052 11/1/2022 N/A
Testosterone Testing CPCPLAB009 11/1/2022 N/A
Thyroid Disease Testing CPCPLAB019 2/1/2023 N/A
Urine Culture Testing for Bacteria CPCPLAB050 11/1/2022 N/A
Vectra DA Blood Test for Rheumatoid Arthritis CPCPLAB039 11/1/2022 N/A
Venous and Arterial Thrombosis Risk Testing CPCPLAB058 11/1/2022 N/A
Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010 2/1/2023 N/A
Vitamin D CPCPLAB003 2/1/2023 N/A
ZIKA Virus Risk Assessment CPCPLAB042 2/1/2023 N/A