Laboratory Service Policies

Find the policy you need below.

On behalf of Capital, laboratory service policies are administered by EviCore.

All providers will be required to comply with the medical policy criteria outlined in these policies. This requirement applies to outpatient laboratory services across all provider types, including:

  • Independent laboratories.
  • Physician's office laboratories.
  • Hospital-based laboratories.

Medical policy enforcement will occur during claims adjudication. Laboratory services that do not meet applicable coverage criteria will be considered non-covered by Capital.

Coverage criteria for laboratory service claims are outlined in the policies listed below.

To learn more, access EviCore’s Clinical Guidelines and CPT Codes.

Clinical use guidelines

  • Infectious Disease Laboratory Testing
  • Medically Necessary Laboratory Testing

Test specific guidelines

  • Allergy Laboratory Testing
  • Cardiovascular Risk and Disease Laboratory Testing
  • Celiac Disease Testing
  • Chromosome Analysis for Reproductive Disorders, Prenatal Testing, and Developmental Disorders
  • Cognitive Impairment Biomarkers
  • Cologuard Plus Screening for Colorectal Cancer
  • Drug Testing
  • Flow Cytometry
  • Gastrointestinal Pathogen Panel (GIPP) Molecular Testing
  • Human Immunodeficiency Virus Laboratory Testing
  • Human Papillomavirus (HPV) Molecular Testing
  • Helicobacter pylori Laboratory Testing
  • Immunohistochemistry (IHC)
  • Inflammatory Biomarkers
  • Inflammatory Bowel Disease Biomarker Testing
  • Insulin and Related Peptides
  • Liver Fibrosis Assessment Biomarkers
  • Lyme Disease Testing
  • Metabolic Testing
  • Mineral Testing
  • Pathology Testing with Mohs Micrographic Surgery
  • Nail Disorder Infectious Disease Testing, Including Onychomycosis
  • Non-Molecular Biomarkers in Oncology
  • Obsolete Tests
  • Prostate Specific Antigen Testing
  • Pancreatitis Laboratory Testing
  • Parathyroid Hormone Testing
  • Prenatal Aneuploidy FISH Testing
  • Prenatal Maternal Serum Screening
  • Reproductive Hormone Testing in Adults
  • Respiratory Infection Pathogen Panel (RIPP) Molecular Testing
  • Rheumatoid Arthritis Laboratory Testing
  • Sexually Transmitted and Other Reproductive Tract Infection Testing
  • Special Histochemical Stains
  • Testosterone Testing
  • Thyroid Disorder Laboratory Testing
  • Urinary Tract Infection Molecular Testing
  • UroVysion FISH for Bladder Cancer
  • Vitamin B12 and Folate Deficiency Testing
  • Vitamin D Testing
  • Vitamin Testing

Administrative guidelines

  • Date of Service and Authorization Period Effective Date
  • Laboratory Billing and Reimbursement
  • Laboratory Testing Procedure Code Requirements
  • Medical Necessity Review Information Requirements
  • Medicare: Hierarchy for Applying Coverage Decisions for Laboratory Testing
  • Special Circumstances Influencing Coverage Determinations
  • Unique Test Identifiers for Non-Specific Procedure Codes