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    MolDx
    Technical Assessment Forms

    TA Form
    Required Tests
    M00151 (TA Checklist)
    All tests submitting TAs
    M00153 (Solid Tumor)
    NGS “Targeted Panel” described by 81445
    NGS “Comprehensive Genomic Profile” — solid tumor
    M00154 (Hematopoietic Malignancy)
    NGS “Targeted Panel” described by 81450
    NGS “Comprehensive Genomic Profile” — hematopoietic malignancy
    M00116 (TA Summary Form)
    NGS Test with results that are either novel or proprietary technology/algorithms. Reserved for tests that require an evaluation of clinical utility or clinical validity that is not already established in existing policies or standards of care.
    M00119 (CGP, Somatic and Germline)
    NGS “Comprehensive Genomic Profile” — solid tumor
    NGS “Comprehensive Genomic Profile” — hematopoietic malignancy
    Whole Exome Sequencing
    Whole Genome Sequencing
    M00155 (Germline)
    NGS germline tests
    M00156 (MolDX PGx Submission Form) Pharmacogenomics (PGx) tests
    Additional Documentation —
    Page 2 of TA Checklist
    NGS “Comprehensive Genomic Profile”
    Test based on novel/proprietary technology or algorithms
    Whole Exome Sequencing
    Whole Genome Sequencing

     

    last updated on 07/17/2020
    ver 1.0.51