Does C00.5 require prior authorization?

No, C00.5 does not require prior authorization (high confidence). Covered without prior authorization.

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`C00.5`, Malignant neoplasm of lip, unspecified, inner aspect

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Select and report the appropriate CPT code for the Next-Generation Sequencing for Solid Tumors service.
Enter 1 unit of service (UOS) for the reported CPT code.
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for Part B electronic claims (Loop 2400 or SV101-7 for 837P) and for Part B paper claims (Box 19).
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for Part A electronic claims (Line SV202-7 for 837I) and on the UB-04 (Block 80) for Part A paper claims.

Key Coverage Criteria

Initial MRD testing is covered for patients with cancer when baseline tumor profiling from a prior analysis is utilized, using listed bespoke/plasma-series MRD tests (e.g., Signatera Bespoke Assay Design + Plasma Series Bundle, RaDaR Bespoke Assay Design + Plasma Series Bundle, Oncodetect Bespoke Assay Design + Plasma Test Bundle, Guardant Reveal MRD Bundle, Guardant360 Response).
Subsequent MRD testing for patients with cancer is covered only if there is clinical evidence of an a priori change in tumor genetic content in accordance with NCD 90.2.
Initial MRD testing is covered for patients without current cancer (per policy definition) when baseline tumor profiling from a prior analysis is utilized, using listed recurrence-monitoring bespoke + single-plasma tests (e.g., Signatera Recurrence Monitoring Bespoke Assay Design + single Plasma Test, RaDaR Recurrence Monitoring, Oncodetect Bespoke Assay, Pathlight Recurrence Monitoring).
Subsequent MRD testing for patients without cancer is covered as specified for listed single-plasma recurrence-monitoring tests (e.g., Signatera Recurrence Monitoring single Plasma Test, RaDaR Recurrence Monitoring single Plasma Test, Oncodetect single Plasma Test, Pathlight Recurrence Monitoring single Plasma Test).
Tumor‑naïve MRD testing (baseline tumor profiling not utilized) is covered for specified single-plasma tests (e.g., NavDX single Plasma Test, Guardant Reveal single Plasma Test).
Covered clinical-validity indications include diagnosis of disease progression, recurrence, or relapse for advanced colorectal cancer, muscle‑invasive bladder cancer, ovarian cancer, neoadjuvant breast cancer (Signatera), and HPV‑negative head and neck squamous cell carcinoma (RaDaR).

20 Active Policies

CGS-J15-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J15

CGS-J15-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J15

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C00.5, Malignant neoplasm of lip, unspecified, inner aspect