Medical Policy

W-2263-001

Policy Id

HHO-WV-RP-2263

Topic

Physician Office Lab Testing

Section

Visits

Effective Date

Nov 01, 2025

Issued Date

Oct 01, 2025

Last Revision Date

07/2025

DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

 

80051

Electrolyte panel This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295)

80305

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; Capable of being read by direct optical observation only (eg utilizing immunoassay (eg, dipsticks, cups, cards, or cartridges), includes sample validation when performed, per date of service

80306

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [dipsticks, cups, cards, or cartridges), includes sample validation when performed, per date of service

 

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; ; By instrument chemistry analyzers (eg Utilizing Immunoassay [ eg, Eia, Elisa, Emit, Fpia, Ia, Kims, Ria]) Chromoatography (eg, Gc, Hplc), and mass spectrometry either with our without chromosaophrau (eg, Dart, Desi, Gc-ms, Gc-ms/ms, Lc-ms/ms, Ldtd, Maldi, Tof) includes sample validation when performed, per date of service

 

80324

Amphetamines; 1 or 2

80325

Amphetamines; 3 or 4

81000

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, Ph, Protein, specific gravity, uroblinogen, any number of these constituents, non-automated, with microscopy

81001

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, Ph, Protein, specific gravity, uroblinogen, any number of these constituents,; automated with microscopy

81002

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, Ph, Protein, specific gravity, uroblinogen, any number of these constituents, non-automated, without microscopy

81003

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, Ph, Protein, specific gravity, uroblinogen, any number of these constituents,; automated without microscopy

81005

Urinalysis; qualitative or semiquantitative, except immunoassays

81015

Urinalysis; microscopic only

81025

Urine pregnancy test, by visual color comparison methods

81513

Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis

81514

Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported

82043

Alburnin; Urine (eg, Microalburnin), quanitative

82044

Alburnin; Urine (eg, Microalburnin), semiquanitative (eg, reagent strip assay)

82247

Bilirubin; total

82270

Blood, occult, by peroxidase activity (eg, guaiac) , qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)

82271

Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources

82272

Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, 1-3 simultaneous deteriminations, performed for other than colorectal neoplasm screening

82374

Assay blood carbon dioxide

82435

Assay of blood chloride

82465

Cholesterol, serum; or whole blood, total

82565

Creatinine; blood

82731

Fetal fibronectin, cervicovaginal secretions, semi-quantitative

82947

Glucose, quantitative, blood( except reagent strip)

82948

Glucose; blood, reagent strip

82950

Glucose post dose (includes glucose)

82951

Glucose; tolerance test (gtt), 3 specimens ( includes glucose)

82952

Glucose; tolerance test, each additional beyond 3 speciments (list separately in addition to code for primary procedure)

82962

Glucose, blood, by glucose monitoring service(s) cleared by the fda specifically for home use

82310

Calcium; total

83036

Hemoglobin; glycosylated (a1c)

83037

Hemoglobin; glycosylated (a1c) by device cleared by Fda for home use

83655

Lead

83690

Lipase

83825

Mercury, quantitative

83861

Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity

83986

PH, Body fluid, not otherwise specified

83992

Phencyclidine(pcp)

84075

Phosphatase, alkaline;

84132

Potassium; serum, plastma or whole blood

84295

Sodium; serum, plasma or whole blood

84315

Specific gravity (except urine)

84450

Transferase; aspartate amino (AST) (SGOT)

84460

Transferase; alanine amino (ALT) (SGPT)

84703

Gonadotropin, chorionic(hcg); Qualitative

85013

Blood count; spun microhematocrit

85014

Blood count; hematocrit (hct)

85018

Blood count; hemoglobin (hgb)

85025

Blood count; complete (cbc), automated (hbg, Hct, rbc, Wbc and platelet count) and automated differential wbc count

85027

Blood count; complete (cbc), automated (hbg, Hct, rbc, Wbc and platelet count)

85049

Blood count; platelet, automated

85730

Thromboplastin time, partial (PTT); plasma or whole blood

86147

Cardiolipin (phospholipid) antibody, each Ig class

85610

Protrombin time

85651

Sedimentation rate, erytocryte; non-automated

86308

Heterophile antibodies; screening

86309

Heterophile antibodies; titer

86318

Immunoassay for infectious agent antibody, qualitative or semiquantitative , single step method (eg, Reagent Strip)

86328

 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease

86408

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen”

86409

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer

86580

Skin test; tuberculosis, patch or intradermal

86756

Antibody; respiratory syncytial virus

86769

Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease

87070

Culture, bacterial; any other source except urine, blood or stool, aerobic; with isolation and presumptive identification of isolates

87172

Pinworm exam (e.g. Cellophane tape prep)

87205

Smear, primary source with interpretation; gram or Giemsa stain for bacteria, fungi, or cell types

87210

Smear, primary source with interpretation; wet mount for infectious agents (e.g. saline, india ink, koh preps)

87220

Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g, scabies)

87270

Infectious agent antigen detection by immunofluorescent technique; chlamydia trachomatis

87301

Infectious agent antigen detection by immunofluorescent technique, (eg, enzyme immunoassay [eia], Enzyme-linked immunosorbent assay [elisa],immunochemiluminometric assay [imca] qualitative or semiquanitative, multiple step method; adenovirus enteric types 40/31

87400

Infectious agent antigen detection by immunofluorescent technique, (eg, enzyme immunoassay [eia], Enzyme-linked immunosorbent assay [elisa],immunochemiluminometric assay [imca] qualitative or semiquantitative, multiple step method; influenza A or B, each

87426

Infectious agent antigen detection by immunoassay technique, qualitative, for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID

87428

 “Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA]

87430

Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [eia], Enzyme-linked immunosorbent assay [elisa],immunochemiluminometric assay [imca] qualitative or semiquantitative, multiple step method; Streptococcus, group A

87490

Infectious agent  detection by nucleic acid (dna or Rna); chlamydia trachomatis, direct probe technique

87491

Infectious agent  detection by nucleic acid (dna or Rna); chlamydia trachomatis, amplified probe technique

87492

Infectious agent  detection by nucleic acid (dna or Rna); chlamydia trachomatis, quantification

87502

Influenza dna amp probe

87634

RSV Dna/ rna amp probe

87635

procedure for detecting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus

87651

Strep A DNA Amp probe

87800

Infectious agent  detection by nucleic acid (dna or Rna); multiple organisms ; direct probe(s) technique

87802

Infectious agent  detection by immunoassay with direct optical observation; streptococcus, group B

87811

 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

87880

Infectious agent  detection by immunoassay with direct optical observation; streptococcus, group A

89050

Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood;

89051

Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count

G0480

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolites if performed

 

References

BMS

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Contact Us

For questions related to this policy, contact the Highmark Government Market Policy Team at GovernmentPolicy@Highmark.com