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Code Restrictions Removed under TRICARE® Laboratory Developed Test Demonstration

Tuesday, March 26, 2019

Laboratory developed tests (LDTs), also known as molecular testing, are diagnostic tests designed, manufactured and used by a single laboratory. In order for an LDT to be considered for coverage under TRICARE, it must meet specific requirements. Effective March 26, 2019, TRICARE is removing Common Procedural Terminology (CPT)® code restrictions for all LDTs covered under its LDT Demonstration Project, and adding 11 new tests.

Coverage requirements 
The following requirements must be met in order for an LDT to be covered under TRICARE:

  • The LDT must be listed in Health Net Federal Services, LLC’s (HNFS) Laboratory Developed Test Coverage Criteria Guide (see also the TRICARE Operations Manual [TOM], Chapter 18),
  • The laboratory must be a TRICARE-authorized and Clinical Laboratory Improvement Amendments (CLIA)-certified provider, and 
  • The beneficiary must meet TRICARE coverage criteria for the specific LDT and have received appropriate genetic testing counseling. 

Except for cystic fibrosis, LDTs require prior authorization. Attach a completed LDT Letter of Attestation to your online request.

U.S. Federal Drug Administration (FDA) approval
Laboratory developed tests approved by the FDA whose results will influence the medical management of an individual are covered under the TRICARE basic benefit. Certain LDTs not yet approved by the FDA are covered under TRICARE’s LDT Demostration Project. 

What is changing? 
Effective March 26, 2019, TRICARE has removed CPT® code restrictions on covered LDTs. Refer to HNFS’ updated LDT Coverage Criteria Guide for LDT CPT® codes now billable under TRICARE. Additionally, 11 new LDTs are being added to the demonstration with varying retroactive dates of implementation. Please review the TOM, Chapter 18 to see all LDTs, along with their respective effective dates. HNFS has removed most LDT-related request types, or authorization templates, from our online authorization submission tools and reference guides. Providers should select request type P162 (Non-USFDA LDTs Demo) and enter the specific CPT® code(s) for the test(s) which they seek covereage for when requesting HNFS approval. 

For more information, visit the Laboratory Developed Tests details page.