Formulary Notes – Kentmere Health

Column:	Description:	Option Definitions:
Formulary Classification	Formulary classification is our recommendation of how a code should be treated within medical and/or reimbursement policy. All codes will be classified as either Genetic Counseling, Not Covered, Payable and/or Preauthorization.	Genetic Counseling (GC) requires pre-test genetic counseling. Not Covered is a recommendation that test, or components of the test under this code, do not demonstrate clinical validity and/or utility at this time and should not be paid. Payable is a recommendation that tests under this code should be paid according to standard plan policy and do not require any additional processing or review unless automated prior authorization is in place. Preauthorization (PA) is a recommendation that tests under this code be required to submit sufficient documentation to allow a coverage determination to be made. This may be automated or manual.
CPT Code	CPT Code is the individual code number as assigned by the AMA or CMS.
CPT Code Description	CPT Code Description is the long description as defined by the AMA or CMS.
Category	Category assigned will designate a code as Biochem analyte/serum component, Biomarker, Classification, Diagnosis, Disease Status, Guidance, Guidance/Biomarker, Identity, Monitoring, Organ Function Status, Other, Risk, Screening or Screening/Surveillance This indicates the general goal of the test.	Biochem analyte/serum component means the tests in this category measure a level, not a variant, that exists in blood or tissue. Biomarker means the results of the tests will be indicative of the presence of a disease, infection or environmental exposure. Classification means the tests in this category will assist in classifying a disease. Diagnosis means the tests in this category will assist in diagnosing a disease. Diagnosis/Guidance means the tests in this category will assist in diagnosing a disease and assist in guiding therapy. Disease Status means the level of activity of a disease. Guidance means the tests in this category will assist in guiding therapy for a disease. Guidance/Biomarker means the results of the tests will either guide prognosis or management. Identity means the tests in this category will assist in an investigative analysis. Monitoring means looking for adverse activity or disease response. Organ Function Status means measuring any of the component functions of the organ. Risk means the tests in this category will assist in evaluating the level of risk for a disease. Screening means a test performed on a select population to identify those who have or are likely to develop a specified disease. Surveillance means a test used to detect the recurrence of a condition. Screening/Surveillance means a test used to detect a condition or a recurrence of that condition.
Disease State	Disease State(s) will list the general category of disease such as cancer, genetic (acquired and/or inherited), neurologic, etc.	Biomarker, Cancer, Cancer/Therapeutic Biomarker, Cardiovascular, Gastrointestinal Disorder, Genetic, Genetic/ Congenital Abnormality, Genetic/Inherited Disease, Hematology, HLA and Self Antigens, Homeostasis, Immune Disorder, Infectious Disease, Kidney Disease, Liver Disease, Leukemia/Lymphoma, Maternity, Maternity/Infertility, Metabolism, Neurodegenerative, Neurodevelopmental, Neurologic, Neurologic/Psychiatry, Neuromuscular, Ophthalmology, Organ Dysfunction, Pharmacogenetics, Psychiatry, Pulmonary Disease, Renal Disease, Solid Organ Neoplasm, Solid Organ Neoplasm/Leukemia, Therapeutics, Toxicology, Transplantation, Transplantation/Maternity
Medical Policy Guidance	Medical Policy Guidance(s) will list one or more specific Kentmere developed Medical Policy Guidance(s) category that includes this code, where available.
Laboratory & Test	Laboratory(ies) & Test(s) will contain select tests specifically attributable to the corresponding CPT code.