MEDICAL POLICY SUBJECT: GENETIC ASSAY OF TUMOR TISSUE TO DETERMINE PROGNOSIS OF BREAST CANCER (OncotypeDX
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SUBJECT: GENETIC ASSAY OF TUMOR TISSUE TO DETERMINE PROGNOSIS OF BREAST CANCER (OncotypeDX TM , MammaPrint®) POLICY NUMBER: 2.02.27 CATEGORY: Laboratory Test EFFECTIVE DATE: 04/21/05 REVISED DATE: 04/20/06, 08/16/07, 10/23/08, 10/29/09, 12/16/10, 11/17/11, 11/15/12, 2/20/14, 01/22/15, 02/18/16, 03/16/17 (DELETED DATE: 11/21/13-2/20/14) PAGE: 1 OF: 9 • If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply. • If a commercial product, including an Essential Plan product, covers a specific service, medical policy criteria apply to the benefit. • If a Medicare product covers a specific service, and there is no national or local Medicare coverage decision for the service, medical policy criteria apply to the benefit.
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