| CPT | Policy Number | Title | Original Effective Date | Last Revised |
| 80061 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 80074 | 190.33 | Hepatitis Panel/Acute Hepatitis Panel | 11/25/2002 | 10/1/2009 |
| 80162 | 190.24 | Digoxin Therapeutic Drug Assay | 11/25/2002 | 10/1/2009 |
| 82105 | 190.25 | Alpha-fetoprotein | 11/25/2002 | 10/1/2009 |
| 82270 | 190.34 | Fecal Occult Blood Test | 11/25/2002 | 7/1/2008 |
| 82272 | 190.34 | Fecal Occult Blood Test | 11/25/2002 | 10/1/2009 |
| 82378 | 190.26 | Carcinoembryonic Antigen | 11/25/2002 | 10/1/2009 |
| 82465 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 82523 | 190.19 | Collagen Crosslinks, Any Method | 11/25/2002 | |
| 82728 | 190.18 | Serum Iron Studies | 11/25/2002 | 1/1/2010 |
| 82947 | 190.2 | Blood Glucose Testing | 11/25/2002 | 4/1/2009 |
| 82948 | 190.2 | Blood Glucose Testing | 11/25/2002 | 4/1/2009 |
| 82962 | 190.2 | Blood Glucose Testing | 11/25/2002 | 4/1/2009 |
| 82977 | 190.32 | Gamma Glutamyl Transferase | 11/25/2002 | 1/1/2010 |
| 82985 | 190.21 | Glycated Hemoglobin/Glycated Protein | 11/25/2002 | 1/1/2009 |
| 83036 | 190.21 | Glycated Hemoglobin/Glycated Protein | 11/25/2002 | 1/1/2009 |
| 83540 | 190.18 | Serum Iron Studies | 11/25/2002 | 1/1/2010 |
| 83550 | 190.18 | Serum Iron Studies | 11/25/2002 | 1/1/2010 |
| 83700 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 83701 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 83704 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 83718 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 83721 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 84153 | 190.31 | Prostate Specific Antigen | 11/25/2002 | 10/1/2008 |
| 84436 | 190.22 | Thyroid Testing | 11/25/2002 | 10/1/2009 |
| 84439 | 190.22 | Thyroid Testing | 11/25/2002 | 10/1/2009 |
| 84443 | 190.22 | Thyroid Testing | 11/25/2002 | 10/1/2009 |
| 84466 | 190.18 | Serum Iron Studies | 11/25/2002 | 1/1/2010 |
| 84478 | 190.23 | Lipids Testing | 11/25/2002 | 10/1/2009 |
| 84479 | 190.22 | Thyroid Testing | 11/25/2002 | 10/1/2009 |
| 84702 | 190.27 | Human Chorionic Gonadotropin | 11/25/2002 | 1/1/2007 |
| 85004 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85007 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85008 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85013 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85014 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85018 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85025 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85027 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85032 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85048 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85049 | 190.15 | Blood Counts | 11/25/2002 | 7/1/2008 |
| 85610 | 190.17 | Prothrombin Time (PT) | 11/25/2002 | 10/1/2009 |
| 85730 | 190.16 | Partial Thromboplastin Time (PTT) | 11/25/2002 | 10/1/2009 |
| 86300 | 190.29 | Tumor Antigen by Immunoassay CA 15-3/CA 27.29 | 11/25/2002 | 10/1/2006 |
| 86301 | 190.3 | Tumor Antigen by Immunoassay CA 19-9 | 11/25/2002 | 10/1/2006 |
| 86304 | 190.28 | Tumor Antigen by Immunoassay CA 125 | 11/25/2002 | 10/10/2006 |
| 86689 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 86701 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 86702 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 86703 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87086 | 190.12 | Urine Culture, Bacterial | 11/25/2002 | 10/1/2009 |
| 87088 | 190.12 | Urine Culture, Bacterial | 11/25/2002 | 10/1/2009 |
| 87390 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87391 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87534 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87535 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87536 | 190.13 | Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) | 11/25/2002 | 10/1/2008 |
| 87537 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87538 | 190.14 | Human Immunodeficiency Virus (HIV) Testing (Diagnosis) | 11/25/2002 | 1/1/2009 |
| 87539 | 190.13 | Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) | 11/25/2002 | 10/1/2008 |
| G0103 | 210.1 | Prostate Cancer Screening Tests | 11/25/2002 | |
| G0123 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | |
| G0124 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0141 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0143 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0144 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0145 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0147 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0148 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| G0248 | 190.11 | Home Prothrombin Time INR Monitoring for Anticoagulation Management | 11/25/2002 | 3/19/2008 |
| G0249 | 190.11 | Home Prothrombin Time INR Monitoring for Anticoagulation Management | 11/25/2002 | 3/19/2008 |
| G0250 | 190.11 | Home Prothrombin Time INR Monitoring for Anticoagulation Management | 11/25/2002 | 3/19/2008 |
| G0328 | 210.3 | Colorectal Cancer Screening Tests | 11/25/2002 | |
| P3000 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| P3001 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
| Q0091 | 210.2 | Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer | 11/25/2002 | 4/1/2007 |
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