Does C18.5 require prior authorization?

No, C18.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C18.5`, Malignant neoplasm of splenic flexure

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

When performing endoscopy for indications that are generally not covered, the medical record must include additional documentation demonstrating medical necessity for review.
Providers/suppliers must notify the beneficiary in writing prior to rendering the service if the provider/supplier is aware the test/procedure may not be covered by Medicare (limitation of liability/refund requirements apply when denials are likely).
This coverage determination applies to Part A MAC claims processed by CGS Administrators, LLC for facilities outside the primary geographic jurisdiction that nominated CGS to process claims; bill type codes apply only to Part A MAC providers as specified.
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.

Evaluation of an anorectal adenomatous polyp is covered (adenomatous polyps only).
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.
Colonoscopy is covered for investigation of a positive fecal occult blood test.
Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.
Surveillance colonoscopy is covered for patients with a history of colorectal cancer or adenomatous polyps being followed for neoplasia surveillance.

CGS-J15-L34037, Flow Cytometry

J15

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

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

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

J15

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