| Flow Cytometry | Policy Number | Effective Date | End Date |
| Flow Cytometry | CPCPLAB001 | 08/15/2023 | 01/14/2025 |
| Flow Cytometry | CPCPLAB001 | 01/01/2023 | 08/14/2023 |
| Cervical Cancer Screening | Policy Number | Effective Date | End Date |
| Cervical Cancer Screening | CPCPLAB002 | 09/01/2023 | 01/14/2025 |
| Cervical Cancer Screening | CPCPLAB002 | 01/01/2023 | 08/31/2023 |
| Vitamin D Testing | Policy Number | Effective Date | End Date |
| Vitamin D Testing | CPCPLAB003 | 03/15/2024 | 04/14/2025 |
| Vitamin D Testing | CPCPLAB003 | 06/15/2023 | 03/14/2024 |
| Vitamin D Testing | CPCPLAB003 | 01/01/2023 | 06/14/2023 |
| Diabetes Mellitus Testing | Policy Number | Effective Date | End Date |
| Diabetes Mellitus Testing | CPCPLAB004 | 04/15/2024 | 04/14/2025 |
| Diabetes Mellitus Testing | CPCPLAB004 | 08/15/2023 | 04/14/2024 |
| Diabetes Mellitus Testing | CPCPLAB004 | 01/01/2023 | 08/14/2023 |
| Prostate Biopsies | Policy Number | Effective Date | End Date |
| Prostate Biopsies | CPCPLAB005 | 09/01/2023 | 01/14/2025 |
| Prostate Biopsies | CPCPLAB005 | 01/01/2023 | 08/31/2023 |
| Prostate Specific Antigen (PSA) Testing | Policy Number | Effective Date | End Date |
| Prostate Specific Antigen (PSA) Testing | CPCPLAB006 | 06/15/2023 | 01/14/2025 |
| Prostate Specific Antigen (PSA) Testing | CPCPLAB006 | 01/01/2023 | 06/14/2023 |
| Preventive Screening in Adults | Policy Number | Effective Date | End Date |
| Preventive Screening in Adults | CPCPLAB007 | 01/01/2023 | 08/14/2023 |
| Diagnostic Testing of Iron Homeostasis & Metabolism | Policy Number | Effective Date | End Date |
| Diagnostic Testing of Iron Homeostasis & Metabolism | CPCPLAB008 | 03/15/2024 | 04/14/2025 |
| Diagnostic Testing of Iron Homeostasis & Metabolism | CPCPLAB008 | 06/15/2023 | 03/14/2024 |
| Diagnostic Testing of Iron Homeostasis & Metabolism | CPCPLAB008 | 01/01/2023 | 06/14/2023 |
| Testosterone Testing | Policy Number | Effective Date | End Date |
| Testosterone | CPCPLAB009 | 03/15/2024 | 04/14/2025 |
| Testosterone | CPCPLAB009 | 08/15/2023 | 03/14/2024 |
| Testosterone | CPCPLAB009 | 01/01/2023 | 08/14/2023 |
| Vitamin B12 and Methylmalonic Acid Testing | Policy Number | Effective Date | End Date |
| Vitamin B12 and Methylmalonic Acid Testing | CPCPLAB010 | 01/15/2025 | 04/14/2025 |
| Vitamin B12 and Methylmalonic Acid Testing | CPCPLAB010 | 03/15/2024 | 01/14/2025 |
| Vitamin B12 and Methylmalonic Acid Testing | CPCPLAB010 | 09/01/2023 | 03/14/2024 |
| Vitamin B12 and Methylmalonic Acid Testing | CPCPLAB010 | 01/01/2023 | 08/31/2023 |
| Biomarker Testing for Autoimmune Rheumatic Disease | Policy Number | Effective Date | End Date |
| Biomarker Testing for Autoimmune Rheumatic Disease | CPCPLAB011 | 08/15/2023 | 01/14/2025 |
| Biomarker Testing for Autoimmune Rheumatic Disease | CPCPLAB011 | 01/01/2023 | 08/14/2023 |
| Pre-Operative Testing | Policy Number | Effective Date | End Date |
| Pre-Operative Testing | CPCPLAB012 | 01/01/2023 | 05/23/2023 |
| Allergen Testing | Policy Number | Effective Date | End Date |
| Allergen Testing | CPCPLAB013 | 06/15/2023 | 01/14/2025 |
| Allergen Testing | CPCPLAB013 | 01/01/2023 | 06/14/2023 |
| Prenatal Screening (Nongenetic) | Policy Number | Effective Date | End Date |
| Prenatal Screening (Nongenetic) | CPCPLAB014 | 11/01/2023 | 11/14/2025 |
| Prenatal Screening (Nongenetic) | CPCPLAB014 | 01/01/2023 | 10/31/2023 |
| Hepatitis Testing | Policy Number | Effective Date | End Date |
| Hepatitis Testing | CPCPLAB015 | 03/15/2024 | 01/14/2025 |
| Hepatitis Testing | CPCPLAB015 | 08/15/2023 | 03/14/2024 |
| Hepatitis Testing | CPCPLAB015 | 01/01/2023 | 08/14/2023 |
| Pediatric Preventive Screening | Policy Number | Effective Date | End Date |
| Pediatric Preventive Screening | CPCPLAB016 | 11/01/2023 | 01/14/2025 |
| Pediatric Preventive Screening | CPCPLAB016 | 01/01/2023 | 10/31/2023 |
| Celiac Disease Testing | Policy Number | Effective Date | End Date |
| Celiac Disease Testing | CPCPLAB017 | 11/01/2023 | 01/14/2025 |
| Celiac Disease Testing | CPCPLAB017 | 01/01/2023 | 10/31/2023 |
| Helicobacter Pylori Testing | Policy Number | Effective Date | End Date |
| Helicobacter Pylori Testing | CPCPLAB018 | 06/15/2023 | 01/14/2025 |
| Helicobacter Pylori Testing | CPCPLAB018 | 01/01/2023 | 06/14/2023 |
| Thyroid Disease Testing | Policy Number | Effective Date | End Date |
| Thyroid Disease Testing | CPCPLAB019 | 06/15/2023 | 01/14/2025 |
| Thyroid Disease Testing | CPCPLAB019 | 01/01/2023 | 06/14/2023 |
| Cardiovascular Disease Risk Assessment | Policy Number | Effective Date | End Date |
| Cardiovascular Disease Risk Assessment | CPCPLAB020 | 01/15/2025 | 04/14/2025 |
| Cardiovascular Disease Risk Assessment | CPCPLAB020 | 11/01/2023 | 01/14/2025 |
| Cardiovascular Disease Risk Assessment | CPCPLAB020 | 01/01/2023 | 10/31/2023 |
| Prenatal Screening for Fetal Aneuploidy | Policy Number | Effective Date | End Date |
| Prenatal Screening for Fetal Aneuploidy | CPCPLAB022 | 01/01/2023 | 10/31/2023 |
| Diagnosis of Idiopathic Environmental Intolerance | Policy Number | Effective Date | End Date |
| Diagnosis of Idiopathic Environmental Intolerance | CPCPLAB023 | 01/15/2025 | 04/14/2025 |
| Diagnosis of Idiopathic Environmental Intolerance | CPCPLAB023 | 08/15/2023 | 01/14/2025 |
| Diagnosis of Idiopathic Environmental Intolerance | CPCPLAB023 | 01/01/2023 | 08/14/2023 |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment | Policy Number | Effective Date | End Date |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment | CPCPLAB024 | 11/01/2023 | 01/14/2025 |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment | CPCPLAB024 | 01/01/2023 | 10/31/2023 |
| Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing | Policy Number | Effective Date | End Date |
| Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing | CPCPLAB025 | 11/01/2023 | 01/14/2025 |
| Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing | CPCPLAB025 | 01/01/2023 | 10/31/2023 |
| Fecal Calprotectin Testing | Policy Number | Effective Date | End Date |
| Fecal Calprotectin Testing | CPCPLAB026 | 09/01/2023 | 01/14/2025 |
| Fecal Calprotectin Testing | CPCPLAB026 | 01/01/2023 | 08/31/2023 |
| Testing for Diagnosis of Active or Latent Tuberculosis | Policy Number | Effective Date | End Date |
| Testing for Diagnosis of Active or Latent Tuberculosis | CPCPLAB027 | 09/01/2023 | 01/14/2025 |
| Testing for Diagnosis of Active or Latent Tuberculosis | CPCPLAB027 | 01/01/2023 | 08/31/2023 |
| Immune Cell Function Assay | Policy Number | Effective Date | End Date |
| Immune Cell Function Assay | CPCPLAB028 | 11/01/2023 | 04/14/2025 |
| Immune Cell Function Assay | CPCPLAB028 | 01/01/2023 | 10/31/2023 |
| Intracellular Micronutrient Analysis | Policy Number | Effective Date | End Date |
| Intracellular Micronutrient Analysis | CPCPLAB029 | 06/15/2023 | 01/14/2025 |
| Intracellular Micronutrient Analysis | CPCPLAB029 | 01/01/2023 | 06/14/2023 |
| In Vitro Chemoresistance and Chemosensitivities Assays | Policy Number | Effective Date | End Date |
| In Vitro Chemoresistance and Chemosensitivities Assays | CPCPLAB030 | 11/10/2023 | 01/14/2025 |
| In Vitro Chemoresistance and Chemosensitivities Assays | CPCPLAB030 | 01/01/2023 | 10/31/2023 |
| Measurement of Thromboxane Metabolites for ASA Resistance | Policy Number | Effective Date | End Date |
| Measurement of Thromboxane Metabolites for ASA Resistance | CPCPLAB031 | 09/01/2023 | 10/31/2023 |
| Measurement of Thromboxane Metabolites for ASA Resistance | CPCPLAB031 | 01/01/2023 | 08/31/2023 |
| Oral Cancer Screening and Testing | Policy Number | Effective Date | End Date |
| Oral Cancer Screening and Testing | CPCPLAB032 | 01/15/2025 | 04/14/2025 |
| Oral Cancer Screening and Testing | CPCPLAB032 | 11/01/2023 | 01/14/2025 |
| Oral Cancer Screening and Testing | CPCPLAB032 | 01/01/2023 | 10/31/2023 |
| Diagnostic Testing of Influenza | Policy Number | Effective Date | End Date |
| Diagnostic Testing of Influenza | CPCPLAB033 | 09/01/2023 | 01/14/2025 |
| Diagnostic Testing of Influenza | CPCPLAB033 | 01/01/2023 | 08/31/2023 |
| Salivary Hormone Testing | Policy Number | Effective Date | End Date |
| Salivary Hormone Testing | CPCPLAB034 | 06/15/2023 | 01/14/2025 |
| Salivary Hormone Testing | CPCPLAB034 | 01/01/2023 | 06/14/2023 |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease | Policy Number | Effective Date | End Date |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease | CPCPLAB035 | 11/01/2023 | 01/14/2025 |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease | CPCPLAB035 | 01/01/2023 | 10/31/2023 |
| Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases | Policy Number | Effective Date | End Date |
| Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases | CPCPLAB036 | 11/01/2023 | 01/14/2025 |
| Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases | CPCPLAB036 | 01/01/2023 | 10/31/2023 |
| Serum Tumor Markers for Malignancies | Policy Number | Effective Date | End Date |
| Serum Tumor Markers for Malignancies | CPCPLAB037 | 04/15/2024 | 01/14/2025 |
| Serum Tumor Markers for Malignancies | CPCPLAB037 | 11/01/2023 | 04/14/2024 |
| Serum Tumor Markers for Malignancies | CPCPLAB037 | 01/01/2023 | 10/31/2023 |
| Urinary Tumor Markers for Bladder Cancer | Policy Number | Effective Date | End Date |
| Urinary Tumor Markers for Bladder Cancer | CPCPLAB038 | 01/15/2025 | 04/14/2025 |
| Urinary Tumor Markers for Bladder Cancer | CPCPLAB038 | 08/15/2023 | 01/14/2025 |
| Urinary Tumor Markers for Bladder Cancer | CPCPLAB038 | 01/01/2023 | 08/14/2023 |
| Vectra DA Blood Test for Rheumatoid Arthritis | Policy Number | Effective Date | End Date |
| Vectra DA Blood Test for Rheumatoid Arthritis | CPCPLAB039 | 01/01/2023 | 07/31/2023 |
| Molecular Testing for Chronic Heart Failure | Policy Number | Effective Date | End Date |
| Molecular Testing for Chronic Heart Failure | CPCPLAB040 | 01/01/2023 | 10/31/2023 |
| Erectile Dysfunction | Policy Number | Effective Date | End Date |
| Erectile Dysfunction | CPCPLAB041 | 01/01/2023 | 08/31/2023 |
| ZIKA Virus Risk Assessment | Policy Number | Effective Date | End Date |
| ZIKA Virus Risk Assessment | CPCPLAB042 | 01/01/2023 | 08/31/2023 |
| Evaluation of Dry Eyes | Policy Number | Effective Date | End Date |
| Evaluation of Dry Eyes | CPCPLAB043 | 06/15/2023 | 01/14/2025 |
| Evaluation of Dry Eyes | CPCPLAB043 | 01/01/2023 | 06/14/2023 |
| Lyme Disease Testing | Policy Number | Effective Date | End Date |
| Lyme Disease Testing | CPCPLAB044 | 08/15/2023 | 01/14/2025 |
| Lyme Disease Testing | CPCPLAB044 | 01/01/2023 | 08/14/2023 |
| Pathogen Panel Testing | Policy Number | Effective Date | End Date |
| Pathogen Panel Testing | CPCPLAB045 | 01/15/2025 | 04/14/2025 |
| Pathogen Panel Testing | CPCPLAB045 | 11/01/2023 | 01/14/2025 |
| Pathogen Panel Testing | CPCPLAB045 | 01/01/2023 | 10/31/2023 |
| Biomarkers for Myocardial Infarction and Chronic Heart Failure | Policy Number | Effective Date | End Date |
| Biomarkers for Myocardial Infarction and Chronic Heart Failure | CPCPLAB046 | 11/01/2023 | 01/14/2025 |
| Biomarkers for Myocardial Infarction and Chronic Heart Failure | CPCPLAB046 | 01/01/2023 | 10/31/2023 |
| Pancreatic Enzyme Testing for Acute Pancreatitis | Policy Number | Effective Date | End Date |
| Pancreatic Enzyme Testing for Acute Pancreatitis | CPCPLAB047 | 11/01/2023 | 01/14/2025 |
| Pancreatic Enzyme Testing for Acute Pancreatitis | CPCPLAB047 | 01/01/2023 | 10/31/2023 |
| Folate Testing | Policy Number | Effective Date | End Date |
| Folate Testing | CPCPLAB048 | 11/01/2023 | 01/14/2025 |
| Folate Testing | CPCPLAB048 | 01/01/2023 | 10/31/2023 |
| General Inflammation Testing | Policy Number | Effective Date | End Date |
| General Inflammation Testing | CPCPLAB049 | 11/01/2023 | 01/14/2025 |
| General Inflammation Testing | CPCPLAB049 | 01/01/2023 | 10/31/2023 |
| Urine Culture Testing for Bacteria | Policy Number | Effective Date | End Date |
| Urine Culture Testing for Bacteria | CPCPLAB050 | 11/01/2023 | 01/14/2025 |
| Urine Culture Testing for Bacteria | CPCPLAB050 | 01/01/2023 | 10/31/2023 |
| Diagnostic Testing of Common Sexually Transmitted Infections | Policy Number | Effective Date | End Date |
| Diagnostic Testing of Common Sexually Transmitted Infections | CPCPLAB051 | 01/15/2025 | 04/14/2025 |
| Diagnostic Testing of Common Sexually Transmitted Infections | CPCPLAB051 | 08/15/2023 | 01/14/2025 |
| Diagnostic Testing of Common Sexually Transmitted Infections | CPCPLAB051 | 01/01/2023 | 08/14/2023 |
| Testing for Vector-Borne Infections | Policy Number | Effective Date | End Date |
| Testing for Vector-Borne Infections | CPCPLAB052 | 11/01/2023 | 01/14/2025 |
| Testing for Vector-Borne Infections | CPCPLAB052 | 01/01/2023 | 10/31/2023 |
| Lab Hemolytic Streptococcus Testing | Policy Number | Effective Date | End Date |
| Lab Hemolytic Streptococcus Testing | CPCPLAB053 | 09/01/2023 | 01/14/2025 |
| Lab Hemolytic Streptococcus Testing | CPCPLAB053 | 01/01/2023 | 08/31/2023 |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing | Policy Number | Effective Date | End Date |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing | CPCPLAB055 | 06/15/2023 | 01/14/2025 |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing | CPCPLAB055 | 01/01/2023 | 06/14/2023 |
| Gamma-glutamyl Transferase | Policy Number | Effective Date | End Date |
| Gamma-glutamyl Transferase | CPCPLAB056 | 09/01/2023 | 01/14/2025 |
| Gamma-glutamyl Transferase | CPCPLAB056 | 01/01/2023 | 08/31/2023 |
| Coronavirus Testing in the Outpatient Setting | Policy Number | Effective Date | End Date |
| Coronavirus Testing in the Outpatient Setting | CPCPLAB057 | 03/15/2024 | 04/14/2025 |
| Coronavirus Testing in the Outpatient Setting | CPCPLAB057 | 11/01/2023 | 03/14/2024 |
| Coronavirus Testing in the Outpatient Setting | CPCPLAB057 | 01/01/2023 | 10/31/2023 |
| Venous and Arterial Thrombosis Risk Testing | Policy Number | Effective Date | End Date |
| Venous and Arterial Thrombosis Risk Testing | CPCPLAB058 | 08/15/2023 | 01/14/2025 |
| Venous and Arterial Thrombosis Risk Testing | CPCPLAB058 | 01/01/2023 | 08/14/2023 |
| Diagnosis of Vaginitis including Multi-target PCR Testing | Policy Number | Effective Date | End Date |
| Diagnosis of Vaginitis | CPCPLAB059 | 03/15/2024 | 08/07/2024 |
| Diagnosis of Vaginitis | CPCPLAB059 | 11/01/2023 | 03/14/2024 |
| Diagnosis of Vaginitis | CPCPLAB059 | 08/15/2023 | 10/31/2023 |
| Diagnosis of Vaginitis | CPCPLAB059 | 01/01/2023 | 08/14/2023 |
| Genetic Testing for Adolescent Idiopathic Scoliosis | Policy Number | Effective Date | End Date |
| Genetic Testing for Adolescent Idiopathic Scoliosis | CPCPLAB060 | 01/01/2023 | 08/31/2023 |
| Testing for Alpha-1 Antitrypsin Deficiency | Policy Number | Effective Date | End Date |
| Testing for Alpha-1 Antitrypsin Deficiency | CPCPLAB061 | 09/01/2023 | 01/14/2025 |
| Testing for Alpha-1 Antitrypsin Deficiency | CPCPLAB061 | 01/01/2023 | 08/31/2023 |
| Identification of Microorganisms using Nucleic Acid Probes | Policy Number | Effective Date | End Date |
| Identification of Microorganisms using Nucleic Acid Probes | CPCPLAB063 | 11/01/2023 | 01/14/2025 |
| Identification of Microorganisms using Nucleic Acid Probes | CPCPLAB063 | 01/01/2023 | 10/31/2023 |
| Nerve Fiber Density Testing | Policy Number | Effective Date | End Date |
| Nerve Fiber Density Testing | CPCPLAB064 | 09/01/2023 | 01/14/2025 |
| Nerve Fiber Density Testing | CPCPLAB064 | 01/01/2023 | 08/31/2023 |
| Human Immunodeficiency Virus (HIV) | Policy Number | Effective Date | End Date |
| Human Immunodeficiency Virus (HIV) | CPCPLAB065 | 08/15/2023 | 01/14/2025 |
| Human Immunodeficiency Virus (HIV) | CPCPLAB065 | 01/01/2023 | 08/14/2023 |
| DNA Ploidy Cell Cycle Analysis | Policy Number | Effective Date | End Date |
| DNA Ploidy Cell Cycle Analysis | CPCPLAB066 | 01/01/2023 | 01/31/2023 |
| Testing of Homocysteine Metabolism-Related Conditions | Policy Number | Effective Date | End Date |
| Testing of Homocysteine Metabolism-Related Conditions | CPCPLAB067 | 03/15/2024 | 04/14/2025 |
| Testing of Homocysteine Metabolism-Related Conditions | CPCPLAB067 | 01/01/2023 | 03/14/2024 |
| Onychomycosis Testing | Policy Number | Effective Date | End Date |
| Onychomycosis Testing | CPCPLAB068 | 06/15/2023 | 01/14/2025 |
| Onychomycosis Testing | CPCPLAB068 | 01/01/2023 | 06/14/2023 |
| Immunohistochemistry | Policy Number | Effective Date | End Date |
| Immunohistochemistry | CPCPLAB069 | 03/15/2024 | 04/14/2025 |
| Immunohistochemistry | CPCPLAB069 | 06/15/2023 | 03/14/2024 |
| Immunohistochemistry | CPCPLAB069 | 01/01/2023 | 06/14/2023 |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting | Policy Number | Effective Date | End Date |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting | CPCPLAB070 | 11/01/2023 | 01/14/2025 |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting | CPCPLAB070 | 08/15/2023 | 10/31/2023 |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting | CPCPLAB070 | 01/01/2023 | 08/14/2023 |
| Colorectal Cancer Screening | Policy Number |
Effective Date | End Date |
| Colorectal Cancer Screening | CPCPLAB071 | 08/15/2023 | 01/14/2025 |