Medicare criteria for pathology services

TEST NAMECLINICAL CRITERIATEST FREQUENCY RESTRICTIONS
Activated Protein C Resistance (APC)• Patient history of venous thromboembolism
• Relatives with history of APC resistance
Antithrombin III• Patient history of venous thromboembolism
• First degree relative of a person who has a proven defect
Beta Human Chorionic Gonadotropin (bHCG) (QUANTITATIVE)
Serum Pregnant
• Diagnosis of threatened abortion or follow-up of abortion or diagnosis of ectopic pregnancy
BNP QUANTITAIVE• Diagnosis of heart failure in patients presenting with dyspnoea to a hospital emergency departmentMaximum of 6 tests per 12 month period
Copper, Zinc, Manganese, SeleniumFor any particular test, maximum 3 tests per 12 month period.
CA125, CA15.3, CA19.9
Carcinoembryonic Antigen (CEA)
• Monitoring malignancy or in detection/monitoring hepatic tumours, gestational trophoblastic disease, germ cell tumour
C-Telopeptide of Collagen (CTx)• Monitoring of patients with a proven history of low bone mineral density
Eosinophilic Cationic Protein (ECP)• Monitoring response to Corticosteroid treated asthma in patients under 12 years of ageMaximum of 3 tests within 12 month period
Factor V Leiden Gene Mutation PCR• Proven venous thrombosis or pulmonary embolism
• Proven defect of this mutation in a first-degree relative
Free T3 Triiodothyronine• For FT3 and TSH Thyroid history and medication must be written with the clinical history notes
NOTE: FT3 is only available with a TSH
Free T4 Thyroxine• For FT4 and TSH Thyroid history and medication must be written with the clinical history notes
NOTE: FT4 is only available with a TSH
Fructosamine• Established diabetesMaximum of 4 tests within 12 month period
Haemochromatosis Gene Test• Repeated elevation of transferrin saturation or serum ferritin
• First-degree relative with diagnosis of haemochromatosis
Haemoglobin A1c Monitoring (HbA1c)• Established diabetesMaximum of 4 tests within 12 month period
Haemoglobin A1c DIAGNOSTIC• For the diagnosis of diabetes in asymptomatic patients at high riskMaximum of 1 test within 12 month period
Hepatitis B (HBV) Viral Load• Hepatitis B surface antigen positive and has chronic hepatitis B and is on antiviral therapyMaximum of 4 tests within 12 month period
Hepatitis C Virus (HCV) Genotyping• Must be requested by specialist or consulting physician managing patient treatment
• Patient is Hepatitis C virus Positive and is being evaluated for antiviral therapy of chronic HCV hepatitis
Maximum of 1 test within 12 month period
Hepatitis C Virus (HCV) PCR Qualitative• Patient is hepatitis C seropositive
• Serologic status is uncertain after testing
• Determination of hepatitis C status of an immunosuppressed or iimmunocompromised patient
• Detection of acute Hepatitis C prior to seroconversion for the clinical management of the patient
Maximum of 1 tests within 12 month period
Hepatitis C virus (HCV) PCR
Qualitative assessment of antiviral therapy
• Patient is undertaking antiviral therapy for hepatitis CMaximum of 4 tests within 12 month period
Hepatitis C virus (HCV) Quantitative• Must be requested by specialist or consulting physician managing patient treatment
• Patient has undergone pre-treatment evaluation for antiviral therapy for chronic hepatitis
Maximum of 2 tests within 12 month period
TEST NAMECLINICAL CRITERIATEST FREQUENCY RESTRICTIONS
Hepatitis Serology• Clinical history indicates clinical hepatitis2 tests per request
Human Papilloma Virus (HPV)• Within 2 years of patient receiving treatment of high grade squamous intraepithelial (HSIL) abnormality of the cervix
• Patient has positive HPV test result and is undergoing annual cytological review for follow-up of treated HSIL
Maximum 2 tests in a 24 month period
Prostate Specific Antigen (PSA) Quantitation• Result between age related reference limit and 10 ug/ml4 tests per 12 month period
PSA (Free Total Ratio)• Follow up of PSA result that lies at or above the age related median but below the age related, method specific 97.5% reference limit1 test per 12 month period
Prostate Specific Antigen (PSA) TotalMaximum of 1 test within 12 month period UNLESS monitoring diagnosis of prostate disease
Protein C• History of venous thromboembolism
• Relative with diagnosis of protein C deficiency
Protein S• History of venous thromboembolism
• Relative with diagnosis of protein S deficiency
RAST4 tests per 12 month period
Thrombophilia Screen• Proven history of venous thromboembolism
• Relative with a proven defect of Antithrombin III, Protein C, Protein S, or APC
Thyroid Function Test (TFT)• TSH and/or T4, thyroid history and medications must be included in clinical notes or a TSH only will be performed
• FT4/FT3 must have clinical history, or will only be performed if TSH is abnormal
Tumour Markers (AFP, bHCG, CA125, CA15.3, CA19.9, CEA, Thyroglobulin)• A rebate is available for tests performed in monitoring malignancy or in the detection of hepatic tumours, gestational trophoblastic disease or germ cell tumour
Urine Drug Screen• Patient in drug abuse treatment program
• Patient undergoing sleep study
• Patient undergoing psychiatric disorder treatment
36 tests within a 12 month period
NOTE: For patients in drug abuse treatment program
Vitamin 1, B1, B2, B3, B6, C and EMaximum of 1 request for 1 or more tests in each 6 month period
Vitamin B12 TotalMaximum of 1 test within 12 month period
Vitamin D
(Routine Vitamin D testing)
One of the following MUST be indicated on the request form:
• Signs or symptoms of osteoporosis or osteomalacia
• Increased alkaline phosphatase and normal LFT
• Hyperparathyroidism, hypo/hypercalcaemia or hypophosphataemia
• Malabsorption or bariatric surgery
• Severe lack of sun exposure, deeply pigmented skin
• Taking medication that is known to decrease 25OH-D levels
• Chronic renal failure or renal transplant recipient
• Less than 16 years of age and has symptoms of rickets
• An infant whose mother has diagnosed Vitamin D deficiency
• Is an exclusively breast-fed baby and has risk factors as mentioned
• A sibling less than 16 years of age and has Vitamin D deficiency