Medical_Policy

Mountain State Medical Policy Bulletin

Section:	Laboratory
Number:	L-29
Topic:	Evocative/Suppression Testing Panels
Effective Date:	May 29, 2006
Issued Date:	June 12, 2006
Date Last Reviewed:	06/2006

General Policy Guidelines

Indications and Limitations of Coverage

The minimum component tests listed with each panel code must be performed in order for the panel code to be reported. (See the Text Attachment below.)

If fewer than the minimum tests are performed, payment should be made for the individual tests.

Do not combine the charges for evocative/suppression testing panels (80400-80440) with organ or disease oriented panel tests (80050-80076) if reported separately.

See Medical Policy Bulletin L-27 for information regarding organ or disease oriented panels.

Description

Evocative/suppression panels (80400-80440) involve the administration of evocative or suppressive agents, and the baseline and subsequent measurement of their effects on chemical constituents. These codes are to be used for the reporting of the laboratory component of the overall testing protocol.

In the code descriptors where reference is made to a particular analyte (e.g., Cortisol (82533 x 2), the "x 2" refers to the number of times the test for that particular analyte is performed.

Procedure Codes

80400	80402	80406	80408	80410	80412
80414	80415	80416	80417	80418	80420
80422	80424	80426	80428	80430	80432
80434	80435	80436	80438	80439	80440

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 002 of L-29]

[Version 001 of L-29]

Table Attachment

Text Attachment

Evocative/Suppression Testing Panels

80400 ACTH stimulation panel; for adrenal insufficiency

This panel must include the following:

Cortisol (82533 x 2)

80402 for 21 hydroxylase deficiency

This panel must include the following:

Cortisol (82533 x 2)

17 hydroxyprogesterone (83498 x 2)

80406 for 3 beta-hydroxydehydrogenase deficiency

This panel must include the following:

Cortisol (82533 x 2)

17 hydroxypregnenolone (84143 x 2)

80408 Aldosterone suppression evaluation panel (e.g., saline infusion)

This panel must include the following:

Aldosterone (82088 x 2)

Renin (84244 x 2)

80410 Calcium-pentagastrin stimulation panel (e.g., calcium pentagastrin)

This panel must include the following:

Calcitonin (82308 x 3)

80412 Corticotropic releasing hormone (CRH) stimulation panel

This panel must include the following:

Cortisol (82533 x 6)

Adrenocorticotropic hormone (ACTH) (82024 x 6)

80414 Chorionic gonadotrophin stimulation panel; testosterone response

This panel must include the following:

Testosterone (84403 X 2 on three pooled blood samples)

80415 estradiol response

This panel must include the following:

Estradiol (82670 x 2 on three pooled blood samples)

80416 Renal vein renin stimulation panel (e.g., captopril)

This panel must include the following:

Renin (84244 X 6)

80417 Peripheral vein renin stimulation panel (e.g., captopril)

This panel must include the following:

Renin (84244 X 2)

80418 Combined rapid anterior pituitary evaluation panel

This panel must include the following:

Adrenocorticotropic hormone (ACTH) (82024 x 4)

Luteinizing hormone (LH) (83002 x 4)

Follicle stimulating hormone (FSH) (83001 x 4)

Prolactin (84146 x 4)

Human growth hormone (HGH) (83003 x 4)

Cortisol (82533 x 4)

Thyroid stimulating hormone (TSH) (84443 x 4)

80420 Dexamethasone suppression panel, 48 hour

This panel must include the following:

Free cortisol, urine (82530 x 2)

Cortisol (82533 x 2)

Volume measurement for timed collection (81050 x 2)

(For single dose dexamethasone, use 82533)

80422 Glucagon tolerance panel; for insulinoma

This panel must include the following:

Glucose (82947 x 3)

Insulin (83525 x 3)

80424 for pheochromocytoma

This panel must include the following:

Catecholamines, fractionated (82384 x 2)

80426 Gonadotropin releasing hormone stimulation panel

This panel must include the following:

Follicle stimulating hormone (FSH) (83001 x 4)

Luteinizing hormone (LH) (83002 X 4)

80428 Growth hormone stimulation panel (e.g., arginine infusion, I-dopa administration)

This panel must include the following:

Human growth hormone (HGH) (83003 x 4)

80430 Growth hormone suppression panel (glucose administration)

This panel must include the following:

Glucose (82947 x 3)

Human growth hormone (HGH) (83003 x 4)

80432 Insulin-induced C-peptide suppression panel

This panel must include the following:

Insulin (83525)

C-peptide (84681 x 5)

Glucose (82497 x 5)

80434 Insulin tolerance panel; for ACTH insufficiency

This panel must include the following:

Cortisol (82533 x 5)

Glucose (82947 x 5)

80435 for growth hormone deficiency

This panel must include the following:

Glucose (82947 x 5)

Human Growth Hormone (HGH) (83003 x 5)

80436 Metyrapone panel

This panel must include the following:

Cortisol (82533 x 2)

11 deoxycortisol (82634 x 2)

80438 Thyrotrophin releasing hormone (TRH) stimulation panel; one
hour

This panel must include the following:

Thyroid stimulating hormone (TSH) (84443 X 3)

80439 two hour

This panel must include the following:

Thyroid stimulating hormone (TSH) (84443 x 4)

80440 for hyperprolactemia

This panel must include the following:

Prolactin (84146 x 3)

Procedure Code Attachment

Glossary

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

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.