Does C04.1 require prior authorization?

No, C04.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C04.1`, Malignant neoplasm of lateral floor of mouth

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

ESA therapy is covered to treat clinically significant anemia by elevating or maintaining red blood cell levels (as demonstrated by Hgb/Hct) to decrease anemia and reduce the need for transfusions.
End stage renal disease (ESRD) patients on dialysis with anemia (Hgb < 10.0 g/dL or Hct < 30%) are eligible for ESA therapy.
Chronic kidney disease (not on dialysis) patients with anemia (Hgb < 10.0 g/dL or Hct < 30%) and evidence of marked renal dysfunction (serum creatinine >= 3 mg/dL OR creatinine clearance < 60 mL/min OR GFR < 60 mL/min/1.73 m2) are eligible for ESA therapy.
Patients with non-myeloid malignancies who have anemia due to concomitant myelosuppressive chemotherapy are eligible for ESA therapy when the hemoglobin immediately prior to initiation or maintenance is < 10.0 g/dL (Hct < 30%).
Patients with anemia due to AZT and/or other nucleoside reverse transcriptase inhibitors (NRTIs) for HIV/AIDS with Hgb < 10.0 g/dL or Hct < 30% at initiation are eligible for ESA therapy.
Selected patients with myelodysplastic syndromes (MDS) with < 10% blasts, pretreatment erythropoietin level ≤ 500 (units as per lab), and anemia (Hgb < 10.0 g/dL or Hct < 30%) are eligible for ESA therapy.

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

J15

CGS-J15-L38067, MolDX: Next-Generation Sequencing for Solid Tumors

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L36658, Proton Beam Therapy

J15

Ask Backwork about documentation requirements, denial risks, or coverage in your state.