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