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MEDICAL POLICY POLICY TITLE IMMUNE CELL FUNCTION ASSAY POLICY NUMBER MP-9.002 1/1/17 Admin Update. Added Medicare variation to Assays for Vitamins and Metabolic Function (L34914) which indicates limited coverage for CPT code 86352 for listed diagnosis effective 10/1/16. Updating product name from SeniorBlue to BlueJourney. Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 21
