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26.4.13.3 Prognostic Breast and Gynecological Cancer Studies
Prognostic breast and gynecological cancer studies are benefits of the Texas Medicaid Program when ordered by a physician for the purpose of determining the best course of treatment for a patient with breast/gynecological cancers.
Prognostic breast and gynecological cancer studies are divided into two categories: Receptor assays and Her-2/neu.
• Receptor Assays (procedure codes 5-84233 and 5-84234)-The estrogen receptor assay (ERA) and the progesterone receptor assay (PRA) are tests in which a tissue sample is exposed to radioactively tagged estrogen or progesterone. The presence of these receptors can have prognostic significance in breast and edometrial cancer.
•Her-2/neu (procedure codes 5-83890, 5-88237, 5-88239, 5-88271, 5-88274, 5-88291, 5-88342, 5-88360, 5-88361 and 5-88365)-Human epidermal growth factor receptor 2 (Her-2/neu) is responsible for the production of a protein that signals cell growth. The over-expression of Her-2/neu in breast cancer is associated with decreased overall survival and response to some therapies. Each procedure used in the analysis should be coded separately.
Reimbursement for receptor assays (procedure codes 5-84233, 5-84234, 5-88360, and 5-88361) are limited to claims with a diagnosis of breast or uterine cancer as listed in the following table. Receptor testing for other diagnoses will be denied.
The following procedure codes are limited to once per lifetime:
Gene mutation analyses (procedure codes 5-S3820, 5-S3822, and 5-S3823) will not be reimbursed on the same date of service as the following procedure codes:
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