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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-LAB-26 Outpatient Alpha-Fetoprotein Testing Form


Outpatient alpha-fetoprotein testing for Screening of Neural Tube Defects

Indications

(908259) Is the patient pregnant and being screened for neural tube defects? 

Outpatient alpha-fetoprotein testing for Carcinoma of Unknown Primary Site

Indications

(908260) Is the patient's alpha-fetoprotein testing part of an evaluation or management for a carcinoma of unknown primary site? 

Outpatient alpha-fetoprotein testing for Germ Cell Tumors

Indications

(908261) Is the patient receiving alpha-fetoprotein testing as an evaluation or management of germ cell tumors? 

Outpatient alpha-fetoprotein testing for Hepatocellular Carcinoma (HCC)

Indications

(908262) Is the patient being tested for diagnosed HCC, suspected HCC, or considered at high risk for HCC? 

Outpatient alpha-fetoprotein testing for Mediastinal Mass

Indications

(908263) Is the outpatient alpha-fetoprotein testing ordered for evaluating or managing a mediastinal mass? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses outpatient alpha-fetoprotein (AFP) testing.

Clinical Indications

Medically Necessary:

Outpatient alpha-fetoprotein testing is considered medically necessary for any of the following indications:

  1. Screening for neural tube defects in pregnant persons; or
  2. Evaluation or management of the following conditions:
    1. Carcinoma of unknown primary site; or
    2. Germ cell tumors; or
    3. Hepatocellular carcinoma (HCC): diagnosed HCC, suspected HCC, or for those at high risk for HCC; or
    4. Mediastinal mass; or
    5. Ovarian cancer; or
    6. Pelvic mass; or
    7. Retroperitoneal mass; or
    8. Testicular cancer or suspicious testicular mass; or
    9. Thymoma or thymic cancer.

Not Medically Necessary:

Outpatient alpha-fetoprotein testing is considered not medically necessary when the above criteria are not met and for all other indications.