Worth knowing about. For its Medicare Advantage plans, United Healthcare needs to follow Medicare policies, and for genomics, that's mostly local or LCD policies.
United Healthcare publishes a 49 page guide, updated regularly, of which pages 5-49 are an index to the numerous local LCDs and billing articles. Handy to know about.
- It is an unambiguous problem-solving operation that includes deploying a set of rules or calculations requiring computer processing;
- The test result (or a component of the result) is the calculated output of this process, and not an intermediary process;
- The same or similar test result could not be obtained without the use of this process;
- The input for the computation is derived from biological samples using analytical processes, and must include data from the sample submitted for the test;
- The process must:
- Either be required for the analytical result, OR
- If adjunct to the analytical result as a post-analytical process, the calculation itself must be independently found to be reasonable and necessary apart from the other components of the test.
- A gene expression profile test wherein sequencing data must be compared in a calculation to an existing and validated set of profiles to bin it in one of several possible risk stratification groups would require the use of an algorithm as defined above.
- A next generation sequencing (NGS) test that uses computation to identify variants in a sample is not considered as using an algorithm in this context. The calculation in this scenario is seen as an intermediary process.