Lab Benefit Management Program - Avalon CPCP Archives

 

Allergen Testing Policy Number Effective Date End Date
Allergen Testing CPCPLAB013 1/15/2025 9/4/2025
Allergen Testing CPCPLAB013 6/15/2023 1/14/2025
Allergen Testing CPCPLAB013 11/1/2022 8/15/2023
Biomarker Testing for Autoimmune Rheumatic Disease Policy Number Effective Date End Date
Biomarker Testing for Autoimmune Rheumatic Disease CPCPLAB011 1/15/2025 8/7/2025
Biomarker Testing for Autoimmune Rheumatic Disease CPCPLAB011 11/1/2023 1/14/2025
ANA/ENA Testing CPCPLAB011 11/1/2022 8/15/2023
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases Policy Number Effective Date End Date
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases CPCPLAB036 2/1/2024 1/14/2025
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases CPCPLAB036 11/1/2023 1/31/2024
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases CPCPLAB036 11/1/2022 8/15/2023
Biomarkers for Myocardial Infarction and Chronic Heart Failure Policy Number Effective Date End Date
Biomarkers for Myocardial Infarction and Chronic Heart Failure CPCPLAB046 3/1/2024 1/14/2025
Biomarkers for Myocardial Infarction and Chronic Heart Failure CPCPLAB046 11/01/2023 2/29/2024
Cardiac Biomarkers for Myocardial Infarction CPCPLAB046 11/1/2022 8/15/2023
β-Hemolytic Streptococcus Testing Policy Number Effective Date End Date
β-Hemolytic Streptococcus Testing CPCPLAB053 3/1/2024 1/14/2025
β-Hemolytic Streptococcus Testing CPCPLAB053 11/1/2023 2/29/2024
β-Hemolytic Streptococcus Testing CPCPLAB053 11/1/2022 8/31/2023
Cardiovascular Disease Risk Assessment Policy Number Effective Date End Date
Cardiovascular Disease Risk Assessment CPCPLAB020 1/15/2025 4/14/2025
Cardiovascular Disease Risk Assessment CPCPLAB020 3/1/2024 1/14/2025
Cardiovascular Disease Risk Assessment CPCPLAB020 11/1/2023 2/29/2024
Cardiovascular Disease Risk Assessment CPCPLAB020 11/1/2022 8/15/2023
Celiac Disease Testing Policy Number Effective Date End Date
Celiac Disease Testing CPCPLAB017 3/1/2024 1/14/2025
Celiac Disease Testing CPCPLAB017 11/1/2023 2/29/2024
Celiac Disease Testing CPCPLAB017 11/1/2022 8/15/2023
Cervical Cancer Screening Policy Number Effective Date End Date
Cervical Cancer Screening CPCPLAB002 3/1/2024 1/14/2025
Cervical Cancer Screening CPCPLAB002 11/1/2023 2/29/2024
Cervical Cancer Screening CPCPLAB002 11/1/2022 10/31/2023
Colorectal Cancer Screening  Policy Number Effective Date End Date
Colorectal Cancer Screening CPCPLAB071 1/15/2025 8/7/2025
Colorectal Cancer Screening CPCPLAB071 11/1/2023 1/14/2025
Coronavirus Testing in the Outpatient Setting Policy Number Effective Date End Date
Coronavirus Testing in the Outpatient Setting CPCPLAB057 3/15/2024 4/14/2025
Coronavirus Testing in the Outpatient Setting CPCPLAB057 3/01/2024 3/14/2024
Coronavirus Testing in the Outpatient Setting CPCPLAB057 11/01/2023 2/29/2024
Coronavirus Testing in the Outpatient Setting CPCPLAB057 11/1/2022 8/15/2023
Diabetes Mellitus Testing Policy Number Effective Date End Date
Diabetes Mellitus Testing CPCPLAB004 4/15/2024 4/14/2025
Diabetes Mellitus Testing CPCPLAB004 8/15/2023 4/14/2024
Hemoglobin A1c CPCPLAB004 11/1/2022 8/15/2023
Diagnosis of Idiopathic Environmental Intolerance Policy Number Effective Date End Date
Diagnosis of Idiopathic Environmental Intolerance CPCPLAB023 1/15/2025 4/14/2025
Diagnosis of Idiopathic Environmental Intolerance CPCPLAB023 11/01/2023 1/14/2025
Diagnosis of Idiopathic Environmental Intolerance CPCPLAB023 11/1/2022 8/15/2023
Diagnosis of Vaginitis Including Multi-target PCR Testing Policy Number Effective Date End Date
Diagnosis of Vaginitis Including Multi-target PCR Testing CPCPLAB059 1/15/2025 8/7/2025
Diagnosis of Vaginitis Including Multi-target PCR Testing CPCPLAB059 3/15/2024 1/14/2025
Diagnosis of Vaginitis Including Multi-target PCR Testing CPCPLAB059 11/1/2023 3/14/2024
Diagnosis of Vaginitis Including Multi-target PCR Testing CPCPLAB059 8/15/2023 10/31/2023
Diagnosis of Vaginitis Including Multi-target PCR Testing CPCPLAB059 11/1/2022 8/15/2023
Diagnostic Testing of Common Sexually Transmitted Infections Policy Number Effective Date End Date
Diagnostic Testing of Common Sexually Transmitted Infections CPCPLAB051 1/15/2025 4/14/2025
Diagnostic Testing of Common Sexually Transmitted Infections CPCPLAB051 11/1/2023 1/14/2025
Diagnostic Testing of Common Sexually Transmitted Infections CPCPLAB051 11/1/2023 11/1/2023
Diagnostic Testing of Common Sexually Transmitted Infections CPCPLAB051 11/1/2022 8/15/2023
Diagnostic Testing of Influenza Policy Number Effective Date End Date
Diagnostic Testing of Influenza CPCPLAB033 2/1/2024 1/14/2025
Diagnostic Testing of Influenza CPCPLAB033 11/01/2023 1/31/2024
Diagnostic Testing of Influenza CPCPLAB033 11/1/2022 8/31/2023
Diagnostic Testing of Iron Homeostasis & Metabolism Policy Number Effective Date End Date
Diagnostic Testing of Iron Homeostasis & Metabolism CPCPLAB008 3/15/2024 4/14/2025
Diagnostic Testing of Iron Homeostasis & Metabolism CPCPLAB008 6/15/2023 3/14/2024
Diagnostic Testing of Iron Homeostasis & Metabolism CPCPLAB008 11/1/2022 8/15/2023
DNA Ploidy Cell Cycle Analysis Policy Number Effective Date End Date
DNA Ploidy Cell Cycle Analysis  CPCPLAB066 11/1/2022 8/15/2023
Epithelial Cell Cytology in Breast Cancer Risk Assessment Policy Number Effective Date End Date
Epithelial Cell Cytology in Breast Cancer Risk Assessment CPCPLAB024 3/1/2024 1/14/2024
Epithelial Cell Cytology in Breast Cancer Risk Assessment CPCPLAB024 11/1/2023 2/29/2024
Epithelial Cell Cytology in Breast Cancer Risk Assessment CPCPLAB024 11/1/2022 8/15/2023
Erectile Dysfunction Policy Number Effective Date End Date
Erectile Dysfunction CPCPLAB041 11/1/2022 8/31/2023
Erectile Dysfunction CPCPLAB041 11/1/2022 8/31/2023
Evaluation of Dry Eyes Policy Number Effective Date End Date
Evaluation of Dry Eyes CPCPLAB043 1/15/2025 8/7/2025
Evaluation of Dry Eyes CPCPLAB043 6/15/2023 1/14/2025
Evaluation of Dry Eyes CPCPLAB043 11/1/2022 8/15/2023
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Policy Number Effective Date End Date
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis CPCPLAB025 3/1/2024 1/14/2025
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis CPCPLAB025 11/1/2023 2/29/2024
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis CPCPLAB025 11/1/2022 8/15/2023
Fecal Calprotectin Testing in Adults
Policy Number Effective Date End Date
Fecal Calprotectin Testing in Adults
CPCPLAB026 2/1/2024 1/14/2025
Fecal Calprotectin Testing in Adults
CPCPLAB026 11/1/2023 1/31/2024
Fecal Calprotectin Testing in Adults
CPCPLAB026 11/1/2022 8/31/2023
Flow Cytometry Policy Number Effective Date End Date
Flow Cytometry CPCPLAB001 1/15/2025 8/7/2025
Flow Cytometry CPCPLAB001 11/1/2023 1/14/2025
Flow Cytometry CPCPLAB001 11/1/2022 8/15/2023
Folate Testing Policy Number Effective Date End Date
Folate Testing CPCPLAB048 11/1/2023 1/14/2025
Folate Testing CPCPLAB048 11/1/2022 8/15/2023
Gamma-glutamyl Transferase Policy Number Effective Date End Date
Gamma-glutamyl Transferase CPCPLAB056 11/1/2023 1/14/2025
General Inflammation Testing Policy Number Effective Date End Date
General Inflammation Testing CPCPLAB049 11/1/2023 1/14/2025
General Inflammation Testing CPCPLAB049 11/1/2022 8/15/2023
Genetic Testing for Adolescent Idiopathic Scoliosis Policy Number Effective Date End Date
Genetic Testing for Adolescent Idiopathic Scoliosis CPCPLAB060 11/1/2022 8/31/2023
Helicobacter pylori Testing Policy Number Effective Date End Date
Helicobacter pylori Testing CPCPLAB018 1/15/2025 8/7/2025
Helicobacter pylori Testing CPCPLAB018 6/15/2023 1/14/2025
Helicobacter pylori Testing CPCPLAB018 11/1/2022 6/14/2023
Hepatitis C Policy Number Effective Date End Date
Hepatitis C CPCPLAB015 3/15/2024 1/14/2025
Hepatitis C CPCPLAB015 2/1/2024 3/14/2024
Hepatitis C CPCPLAB015 11/1/2023 1/31/2024
Hepatitis C CPCPLAB015 11/1/2022 8/15/2023
Human Immunodeficiency Virus (HIV) Policy Number Effective Date End Date
Human Immunodeficiency Virus (HIV) CPCPLAB065 1/15/2025 8/7/2025
Human Immunodeficiency Virus (HIV) CPCPLAB065 11/1/2023 1/14/2025
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection CPCPLAB065 11/1/2022 8/15/2023
Identification of Microorganisms using Nucleic Acid Probes Policy Number Effective Date End Date
Identification of Microorganisms using Nucleic Acid Probes CPCPLAB063 11/1/2023 1/14/2025
Identification of Microorganisms using Nucleic Acid Probes CPCPLAB063 11/1/2022 8/15/2023
Immune Cell Function Assay
Policy Number Effective Date End Date
Immune Cell Function Assay CPCPLAB028 2/1/2024 4/14/2025
Immune Cell Function Assay CPCPLAB028 11/1/2023 1/31/2024
Immune Cell Function Assay CPCPLAB028 11/1/2022 8/31/2023
Immunohistochemistry Policy Number Effective Date End Date
Immunohistochemistry CPCPLAB069 3/15/2024 4/14/2025
Immunohistochemistry CPCPLAB069 6/15/2023 3/14/2024
Immunohistochemistry CPCPLAB069 11/1/2022 8/15/2023
Intracellular Micronutrient Analysis Policy Number Effective Date End Date
Intracellular Micronutrient Analysis CPCPLAB029 1/15/2025 8/7/2025
Intracellular Micronutrient Analysis CPCPLAB029 6/15/2023 1/14/2025
Intracellular Micronutrient Analysis CPCPLAB029 11/1/2022 8/15/2023
In Vitro Chemoresistance and Chemosensitivities Assays Policy Number Effective Date End Date
In Vitro Chemoresistance and Chemosensitivities Assays CPCPLAB030 2/1/2024 1/14/2025
In Vitro Chemoresistance and Chemosensitivities Assays CPCPLAB030 11/01/2023 1/31/2024
In Vitro Chemoresistance and Chemosensitivities Assays CPCPLAB030 11/1/2022 8/15/2023
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease Policy Number Effective Date End Date
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease CPCPLAB035 2/1/2024 1/14/2025
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease CPCPLAB035 11/1/2023 1/31/2024
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease CPCPLAB035 11/1/2022 8/15/2023
Lyme Disease Policy Number Effective Date End Date
Lyme Disease CPCPLAB044 1/15/2025 8/7/2025
Lyme Disease CPCPLAB044 11/1/2023 1/14/2025
Lyme Disease CPCPLAB044 11/1/2022 8/15/2023
Measurement of Thromboxane Metabolites for ASA Resistance Policy Number Effective Date End Date
Measurement of Thromboxane Metabolites for ASA Resistance CPCPLAB031 11/1/2022 8/31/2023
Nerve Fiber Density Testing Policy Number Effective Date End Date
Nerve Fiber Density Testing CPCPLAB064 3/1/2024 1/14/2025
Nerve Fiber Density Testing CPCPLAB064 11/1/2023 2/29/2024
Nerve Fiber Density Testing CPCPLAB064 11/1/2022 8/15/2023
Onychomycosis Testing Policy Number Effective Date End Date
Onychomycosis Testing CPCPLAB068 1/15/2025 8/7/2025
Onychomycosis Testing CPCPLAB068 6/15/2023 1/14/2025
Onychomycosis Testing CPCPLAB068 11/1/2022 8/15/2023
Oral Cancer Screening and Testing Policy Number Effective Date End Date
Oral Cancer Screening and Testing CPCPLAB032 1/15/2025 4/14/2025
Oral Cancer Screening and Testing CPCPLAB032 11/1/2023 1/14/2025
Oral Screening Lesion Identification Systems and Genetic Screening CPCPLAB032 11/1/2022 8/15/2023
Pancreatic Enzyme Testing for Acute Pancreatitis Policy Number Effective Date End Date
Pancreatic Enzyme Testing for Acute Pancreatitis CPCPLAB047 11/1/2023 1/14/2025
Pancreatic Enzyme Testing for Acute Pancreatitis CPCPLAB047 11/1/2022 8/15/2023
Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing Policy Number Effective Date End Date
Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing CPCPLAB055 1/15/2025 8/7/2025
Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing CPCPLAB055 6/15/2023 1/14/2025
Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing CPCPLAB055 11/1/2022 8/15/2023
Pathogen Panel Testing Policy Number Effective Date End Date
Pathogen Panel Testing CPCPLAB045 1/15/2025 4/14/2025
Pathogen Panel Testing CPCPLAB045 3/1/2024 1/14/2025
Pathogen Panel Testing CPCPLAB045 11/1/2023 2/29/2024
Pathogen Panel Testing CPCPLAB045 11/1/2022 8/15/2023
Pediatric Preventive Screening Policy Number Effective Date End Date
Pediatric Preventative Screening CPCPLAB016 1/15/2025 8/7/2025
Pediatric Preventative Screening CPCPLAB016 11/1/2023 1/14/2025
Pediatric Preventative Screening CPCPLAB016 11/1/2022 8/15/2023
Prenatal Screening (Nongenetic) Policy Number Effective Date End Date
Prenatal Screening (Nongenetic) CPCPLAB014 1/16/2025 5/1/2025
Prenatal Screening (Nongenetic) CPCPLAB014 11/01/2023 1/14/2025
Prenatal Screening (Nongenetic) CPCPLAB014 11/1/2023 10/31/2023
Prenatal Screening CPCPLAB014 11/1/2022 8/15/2023
Prenatal Screening for Fetal Aneuploidy Policy Number Effective Date End Date
Prenatal Screening for Fetal Aneuploidy CPCPLAB022 11/1/2023 10/31/2023
Pre-Operative Testing Policy Number Effective Date End Date
Pre-Operative Testing CPCPLAB012 11/1/2022 5/30/2023
Prescription Medication and Illicit Drug Testing in the Outpatient Setting  Policy Number Effective Date End Date
Prescription Medication and Illicit Drug Testing in the Outpatient Setting CPCPLAB070 1/15/2025 9/4/2025
Prescription Medication and Illicit Drug Testing in the Outpatient Setting  CPCPLAB070 11/1/2023 1/14/2025
Prescription Medication and Illicit Drug Testing in the Outpatient Setting  CPCPLAB070 11/1/2022 8/15/2023
Prescription Medication and Illicit Drug Testing in the Outpatient Setting CPCPLAB070 8/15/2023 10/31/2023
Preventative Screenings in Adults Policy Number Effective Date End Date
Preventive Screening in Adults CPCPLAB007 8/22/2022 8/14/2023
Prostate Biopsies Policy Number Effective Date End Date
Prostate Biopsies CPCPLAB005 2/1/2024 1/14/2025
Prostate Biopsies CPCPLAB005 11/1/2023 1/31/2024
Prostate Biopsies CPCPLAB005 11/1/2022 8/31/2023
Prostate Specific Antigen Testing Policy Number Effective Date End Date
Prostate Specific Antigen Testing CPCPLAB006 1/15/2025 9/4/2025
Prostate Specific Antigen Testing CPCPLAB006 6/15/2023 1/14/2025
Prostate Specific Antigen Testing CPCPLAB006 11/1/2022 8/15/2023
Salivary Hormone Testing Policy Number Effective Date End Date
Salivary Hormone Testing CPCPLAB034 1/15/2025 8/7/2025
Salivary Hormone Testing CPCPLAB034 6/15/2023 1/14/2025
Salivary Hormone Testing CPCPLAB034 11/1/2022 8/15/2023
Serum Tumor Markers for Malignancies Policy Number Effective Date End Date
Serum Tumor Markers for Malignancies CPCPLAB037 4/15/2024 1/14/2025
Serum Tumor Markers for Malignancies CPCPLAB037 3/1/2024 4/14/2024
Serum Tumor Markers for Malignancies CPCPLAB037 11/1/2023 2/29/2024
Serum Tumor Markers for Malignancies CPCPLAB037 11/1/2022 8/15/2023
ST2 Assay for Chronic Heart Failure Policy Number Effective Date End Date
ST2 Assay for Chronic Heart Failure CPCPLAB040 11/1/2022 10/31/2023
Testing for Alpha-1 Antitrypsin Deficiency Policy Number Effective Date End Date
Testing for Alpha-1 Antitrypsin Deficiency CPCPLAB061 11/1/2023 1/14/2025
Testing for Alpha-1 Antitrypsin Deficiency CPCPLAB061 11/1/2022 8/31/2023
Testing for Diagnosis of Active or Latent Tuberculosis Policy Number Effective Date End Date
Testing for Diagnosis of Active or Latent Tuberculosis CPCPLAB027 2/1/2024 1/14/2025
Testing for Diagnosis of Active or Latent Tuberculosis CPCPLAB027 11/1/2023 1/31/2024
Testing for Diagnosis of Active or Latent Tuberculosis CPCPLAB027 11/1/2022 8/31/2023
Testing for Vector-Borne Infections Policy Number Effective Date End Date
Testing for Vector-Borne Infections CPCPLAB052 11/1/2023 1/14/2025
Testing for Mosquito- or Tick-Related Infections CPCPLAB052 11/1/2022 8/15/2023
Testing of Homocysteine Metabolism-Related Conditions Policy Number Effective Date End Date
Testing of Homocysteine Metabolism-Related Conditions CPCPLAB067 3/15/2024 4/14/2025
Testing of Homocysteine Metabolism-Related Conditions CPCPLAB067 11/1/2023 3/14/2023
Testosterone Testing Policy Number Effective Date End Date
Testosterone Testing CPCPLAB009 3/15/2024 4/14/2025
Testosterone Testing CPCPLAB009 11/1/2023 3/14/2024
Testosterone Testing CPCPLAB009 11/1/2022 8/15/2023
Thyroid Disease Testing Policy Number Effective Date End Date
Thyroid Disease Testing CPCPLAB019 1/15/2025 8/7/2025
Thyroid Disease Testing CPCPLAB019 6/15/2023 1/14/2025
Thyroid Disease Testing CPCPLAB019 11/1/2022 8/15/2023
Urinary Tumor Markers for Bladder Cancer Policy Number Effective Date End Date
Urinary Tumor Markers for Bladder Cancer CPCPLAB038 1/15/2025 4/14/2025
Urinary Tumor Markers for Bladder Cancer CPCPLAB038 11/01/2023 1/14/2025
Urinary Tumor Markers for Bladder Cancer CPCPLAB038 11/1/2022 8/15/2023
Urine Culture Testing for Bacteria Policy Number Effective Date End Date
Urine Culture Testing for Bacteria CPCPLAB050 11/1/2023 1/14/2024
Urine Culture Testing for Bacteria CPCPLAB050 11/1/2022 8/15/2023
Vectra DA Blood Test for Rheumatoid Arthritis Policy Number Effective Date End Date
Vectra DA Blood Test for Rheumatoid Arthritis CPCPLAB039 11/1/2022 8/14/2023
Venous and Arterial Thrombosis Risk Testing  Policy Number Effective Date End Date
Venous and Arterial Thrombosis Risk Testing CPCPLAB058 1/15/2025 8/7/2025
Venous and Arterial Thrombosis Risk Testing CPCPLAB058 11/1/2023 1/14/2025
Vitamin B12 and Methylmalonic Acid Testing Policy Number Effective Date End Date
Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010 1/15/2025 4/14/2025
Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010 3/15/2024 1/14/2025
Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010 11/1/2023 3/14/2024
Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010 11/1/2022 8/31/2023
Vitamin D Policy Number Effective Date End Date
Vitamin D CPCPLAB003 3/15/2024 4/14/2025
Vitamin D CPCPLAB003 11/1/2022 8/15/2023
ZIKA Virus Risk Assessment Policy Number Effective Date End Date
ZIKA Virus Risk Assessment CPCPLAB042 11/1/2022 8/31/2023