Laboratory Management
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There may be instances in which your health plan policies take precedence over the EviCore by Evernorth clinical guidelines. If you have any questions, please reach out to your health plan.
Follow the below steps to access the clinical guidelines.
- Enter your Health Plan name into the search field and click on the magnifying glass.
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- Open the guideline document.
Example:
The statement in your letter reads:
We based this decision on the guideline as listed below:
-MTHFR Variant Analysis for Hyperhomocysteinemia (MOL.TX.205).
Enter your Health Plan name into the search field and click on the magnifying glass.
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EviCore coverage policies include background and supporting information and citations for sources used to develop the policy. Some clinical policies may have a supplemental literature summary available which will provide additional commentary regarding clinical benefits and harms to the patient population being served. Additional literature summaries may be accessed by selecting ‘Supplemental Information’ and then entering “EviCore by Evernorth” in the search by health plan function.
Guidelines
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MOL.AD.101.A:Medicare:Hierarchy for Applying Coverage Decisions for Laboratory TestingEffective 07/01/2024 - 12/31/2024
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MOL.AD.107.A Unique Test Identifiers for Non-Specific Procedure CodesEffective 07/01/2024 - 12/31/2024
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MOL.AD.304.A Medical Necessity Review Information RequirementsEffective 07/01/2024 - 12/31/2024
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MOL.AD.314.A Date of Service and Authorization Period Effective DateEffective 07/01/2024 - 12/31/2024
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MOL.AD.364.A Special Circumstances Influencing Coverage DeterminationsEffective 07/01/2024 - 12/31/2024
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MOL.AD.367.W Medicaid Hierarchy for Applying Coverage Decisions for Laboratory Testing for WellCare Managed Medicaid Members in the State of North CarolinaEffective 07/01/2024 - 12/31/2024
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MOL.AD.391.A Laboratory Procedure Code RequirementsEffective 07/01/2024 - 12/31/2024
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MOL.CU.109.A Genetic Testing for Cancer Susceptibility and Hereditary Cancer SyndromesEffective 07/01/2024 - 12/31/2024
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MOL.CU.110.A Genetic Testing for Carrier StatusEffective 07/01/2024 - 12/31/2024
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MOL.CU.111.A Genetic Testing for Non-Medical PurposesEffective 07/01/2024 - 12/31/2024
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MOL.CU.112.A Genetic Testing for Prenatal Screening and Diagnostic TestingEffective 07/01/2024 - 12/31/2024
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MOL.CU.113.A Genetic Testing for the Screening, Diagnosis, and Monitoring of CancerEffective 07/01/2024 - 12/31/2024
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MOL.CU.114.A Genetic Testing to Diagnose Non-Cancer ConditionsEffective 07/01/2024 - 12/31/2024
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MOL.CU.115.A Genetic Testing to Predict Disease RiskEffective 07/01/2024 - 12/31/2024
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MOL.CU.116.A Genetic Testing by Multigene PanelsEffective 07/01/2024 - 12/31/2024
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MOL.CU.117.A Investigational and Experimental Laboratory TestingEffective 07/01/2024 - 12/31/2024
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MOL.CU.118.A Pharmacogenomic Testing for Drug Toxicity and ResponseEffective 07/01/2024 - 12/31/2024
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MOL.CU.119.A Preimplantation Genetic Screening and DiagnosisEffective 07/01/2024 - 12/31/2024
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MOL.CU.246.A Hereditary (Germline) Testing After Tumor (Somatic) TestingEffective 07/01/2024 - 12/31/2024
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MOL.CU.256.A Confirmatory Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.CU.291.A Genetic Testing for Known Familial MutationsEffective 07/01/2024 - 12/31/2024
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MOL.CU.292.A Genetic Testing for Variants of Uncertain Clinical SignificanceEffective 07/01/2024 - 12/31/2024
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MOL.CU.298.A Genetic Presymptomatic and Predictive Testing for Adult-Onset Conditions in MinorsEffective 07/01/2024 - 12/31/2024
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MOL.CU.333.B Medically Necessary Laboratory TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.120.A 4Kscore for Prostate Cancer Risk AssessmentEffective 07/01/2024 - 12/31/2024
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MOL.TS.122.A Afirma Thyroid Cancer Classifier TestsEffective 07/01/2024 - 12/31/2024
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MOL.TS.123.A AlloMap Gene Expression Profiling For Heart Transplant RejectionEffective 07/01/2024 - 12/31/2024
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MOL.TS.124.A Alpha-1 Antitrypsin Deficiency TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.125.A Amyotrophic Lateral Sclerosis (ALS) Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.126.A Angelman Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.128.A APOE Variant Analysis for Alzheimer Disease TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.129.A Ashkenazi Jewish Carrier ScreeningEffective 07/01/2024 - 12/31/2024
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MOL.TS.130.A Ataxia-Telangiectasia Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.144.A CADASIL Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.145.A Canavan Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.148.A Charcot-Marie-Tooth Neuropathy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.150.A Chromosomal Microarray Testing For Developmental Disorders (Prenatal and Postnatal)Effective 07/01/2024 - 12/31/2024
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MOL.TS.151.A Chromosome Analysis for Blood and Bone Marrow CancersEffective 07/01/2024 - 12/31/2024
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MOL.TS.153.A ConfirmMDx for Prostate Cancer Risk AssessmentEffective 07/01/2024 - 12/31/2024
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MOL.TS.158.A Cystic Fibrosis Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.159.A Dentatorubral-Pallidoluysian Atrophy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.161.A Duchenne and Becker Muscular Dystrophy TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.162.A Early Onset Familial Alzheimer Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.164.A SEPT9 Methylation Analysis for Colorectal CancerEffective 07/01/2024 - 12/31/2024
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MOL.TS.165.A Expanded Carrier Screening PanelsEffective 07/01/2024 - 12/31/2024
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MOL.TS.168.A Familial Adenomatous Polyposis Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.169.A Familial Hypercholesterolemia Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.170.A Familial Malignant Melanoma Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.172.A FMR1-Related Disorders (Fragile X) Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.173.A Gaucher Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.182.A Hereditary Cancer Syndrome Multigene PanelsEffective 07/01/2024 - 12/31/2024
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MOL.TS.183.A HFE Hemochromatosis Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.188.A Huntington Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.193.A Li-Fraumeni Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.194.A Liquid Biopsy TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.197.A Lynch Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.199.A Lynch Syndrome Tumor Screening - Second-TierEffective 07/01/2024 - 12/31/2024
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MOL.TS.200.A Mammaprint 70-Gene Breast Cancer Recurrence AssayEffective 07/01/2024 - 12/31/2024
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MOL.TS.202.A Marfan Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.206.A MUTYH Associated Polyposis Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.207.A Niemann-Pick Disease Types A and B GeneticTestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.208.A Niemann-Pick Disease Type C Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.209.A Non-Invasive Prenatal ScreeningEffective 07/01/2024 - 12/31/2024
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MOL.TS.211.A Oncotype DX for Breast Cancer PrognosisEffective 07/01/2024 - 12/31/2024
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MOL.TS.213.A Oncotype DX for Colorectal Cancer Recurrence RiskEffective 07/01/2024 - 12/31/2024
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MOL.TS.215.A: PCA3 Testing for Prostate CancerEffective 07/01/2024 - 12/31/2024
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MOL.TS.216.A: Peutz-Jeghers Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.217.A: Prader-Willi Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.220.A: Prenatal Maternal Serum ScreeningEffective 07/01/2024 - 12/31/2024
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MOL.TS.222.A: Prosigna Breast Cancer Prognostic Gene Signature AssayEffective 07/01/2024 - 12/31/2024
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MOL.TS.223.A: PTEN Hamartoma Tumor Syndromes Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.224.A: Rett Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.225.A: Spinal Muscular Atrophy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.226.A: Tay-Sachs Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.227.A: Thoracic Aortic Aneurysms and Dissections (TAAD) Panel Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.228.A: Tissue of Origin Testing for Cancer of Unknown PrimaryEffective 07/01/2024 - 12/31/2024
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MOL.TS.230.A: Somatic Mutation Testing (previously Somatic Mutation Testing-Solid Tumors)Effective 07/01/2024 - 12/31/2024
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MOL.TS.232.A: VeriStrat Testing for NSCLC TKI ResponseEffective 07/01/2024 - 12/31/2024
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MOL.TS.233.A: Von Hippel-Lindau Disease Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.234.A: EndoPredict for Breast Cancer PrognosisEffective 07/01/2024 - 12/31/2024
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MOL.TS.235.A: Exome SequencingEffective 07/01/2024 - 12/31/2024
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MOL.TS.236.A: CxbladderEffective 07/01/2024 - 12/31/2024
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MOL.TS.238.A: BRCA AnalysisEffective 07/01/2024 - 12/31/2024
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MOL.TS.240.A: BCR-ABL Negative Myeloproliferative Neoplasm TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.248.A: Breast Cancer Index for Breast Cancer PrognosisEffective 07/01/2024 - 12/31/2024
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MOL.TS.250.A: NETestEffective 07/01/2024 - 12/31/2024
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MOL.TS.251.A: PALB2 Genetic Testing for Breast Cancer RiskEffective 07/01/2024 - 12/31/2024
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MOL.TS.254.A: DecisionDX Uveal MelanomaEffective 07/01/2024 - 12/31/2024
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MOL.TS.255.A: Oncotype DX Breast DCISEffective 07/01/2024 - 12/31/2024
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MOL.TS.257.A: Epilepsy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.258.A: Maturity-Onset Diabetes of the Young (MODY) Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.259.A: ThyGeNEXT and ThyraMIR miRNA Gene Expression ClassifierEffective 07/01/2024 - 12/31/2024
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MOL.TS.260.A: OVA1Effective 07/01/2024 - 12/31/2024
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MOL.TS.264.A: SelectMDxEffective 07/01/2024 - 12/31/2024
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MOL.TS.266.A: Mitochondrial Disorders Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.267.A: Ehlers-Danlos Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.268.A: Hereditary Connective Tissue Disorder Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.269.A: Autism, Intellectual Disability, and Developmental Delay Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.270.A: ThyroseqEffective 07/01/2024 - 12/31/2024
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MOL.TS.271.A: PancraGENEffective 07/01/2024 - 12/31/2024
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MOL.TS.273.A: Nonsyndromic Hearing Loss and Deafness Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.276.A: Polymerase Gamma (POLG) Related Disorders Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.282.A: DermTech Pigmented Lesion AssayEffective 07/01/2024 - 12/31/2024
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MOL.TS.285.A: Multiple Endocrine Neoplasia Type 1 Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.286.A: Multiple Endocrine Neoplasia Type 2 Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.287.A: Hereditary Pancreatitis Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.288.A: Limb-Girdle Muscular Dystrophy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.290.A: Facioscapulohumeral Muscular Dystrophy Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.294.A: Decipher Prostate Cancer ClassifierEffective 07/01/2024 - 12/31/2024
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MOL.TS.295.A: Genomic Prostate ScoreEffective 07/01/2024 - 12/31/2024
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MOL.TS.297.A: ProlarisEffective 07/01/2024 - 12/31/2024
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MOL.TS.301.A: Neurofibromatosis Type 1 Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.302.A: Legius Syndrome Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.306.A: Genome SequencingEffective 07/01/2024 - 12/31/2024
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MOL.TS.307.A: AlloSure for Kidney Transplant RejectionEffective 07/01/2024 - 12/31/2024
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MOL.TS.308.A: Hemoglobinopathies Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.309.A: Friedreich Ataxia Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.310.A: Hereditary Ataxia Multigene Panel TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.311.A: Spinocerebellar Ataxia Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.312.A: Myotonic Dystrophy Type 1 Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.324.A: CHARGE Syndrome and CHD7 Disorder Genetic Testing (previously CHARGE Syndrome Genetic Testing)Effective 07/01/2024 - 12/31/2024
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MOL.TS.344.A: Chromosomal Microarray for Solid TumorsEffective 07/01/2024 - 12/31/2024
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MOL.TS.356.A: Microsatellite Instability and Immunohistochemistry Testing in CancerEffective 07/01/2024 - 12/31/2024
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MOL.TS.360.A: Inherited Bone Marrow Failure Syndrome (IBMFS) TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.361.A: Human Platelet and Red Blood Cell Antigen GenotypingEffective 07/01/2024 - 12/31/2024
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MOL.TS.370.A: Inherited Thrombophilia Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.371.A: Noonan Spectrum Disorder Genetic TestingEffective 07/01/2024 - 12/31/2024
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MOL.TS.396.A: Multi-Cancer Early Detection ScreeningEffective 07/01/2024 - 12/31/2024
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MOL.TS.401.A: Liver Fibrosis Assessment BiomarkersEffective 07/01/2024 - 12/31/2024
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MOL.TS.410.A: Cardiomyopathy and Arrhythmia Genetic TestingEffective 07/01/2024 - 12/31/2024