Does C16.4 require prior authorization?

No, C16.4 does not require prior authorization (high confidence). Covered without prior authorization.

`C16.4`, Malignant neoplasm of pylorus

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware the test may not be covered by Medicare.
A pathologist performing additional tests must document why additional testing was done in the report and confirm that the results were communicated to and used by the treating physician/practitioner in the beneficiary's treatment.
Non-physician practitioners (e.g., nurse practitioners, clinical nurse specialists, physician assistants) may certify, order, and establish the plan of care for flow cytometry services as authorized by State law.
For FQHC services with dates of service on or after April 1, 2010, bill type 77X should be used to report flow cytometry services.

Flow cytometry is covered to detect antigens used as therapeutic targets in neoplastic disease.
Flow cytometry is covered for diagnosis and classification of hematopoietic neoplasms.
Flow cytometry is covered to assess biologic parameters associated with prognosis in hematopoietic neoplasms.
Flow cytometry is covered to detect residual neoplastic cells following therapy (minimal residual disease detection).
Flow cytometry is covered to monitor lymphocyte populations in patients with HIV infection.
Flow cytometry is covered to monitor lymphocyte subpopulations in post-transplant patients on immunosuppressive therapy.

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

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

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

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