Does C38.0 require prior authorization?

No, C38.0 does not require prior authorization (high confidence). Covered without prior authorization.

`C38.0`, Malignant neoplasm of heart

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

All CCTA studies must be ordered by the treating physician or qualified non-physician practitioner who will use the results in patient management and must be performed under the direct supervision of a physician.
Clinical documentation must justify the indication, include presenting signs/symptoms, pre-test probability, and prior relevant test results (e.g., stress testing, myocardial perfusion imaging, cardiac ultrasound, prior invasive angiography) demonstrating that CCTA will provide new information to guide management.
Technical personnel performing image acquisition must be credentialed (e.g., ARRT or equivalent) and meet applicable state licensure requirements.
If intravenous beta blockers or nitrates are administered prior to CCTA, direct supervision by a certified registered nurse and a physician experienced with cardiovascular drugs is required and it is strongly recommended these staff be ACLS certified.

CCTA may be used to reliably rule out significant coronary artery disease (CAD) in patients with low to intermediate pre-test probability of CAD as an alternative to an imaging stress test.
CCTA may be used in a patient presenting with chest pain syndrome when the clinician has a high degree of suspicion that CAD is high on the differential diagnosis.
CCTA may be used to facilitate management in select patients who have an equivocal stress test or stress imaging result.
CCTA may be used to evaluate new or recurrent symptoms in patients with known CAD to assess for progression or exacerbation of underlying coronary disease.
CCTA may be used in patients with prior coronary artery bypass graft (CABG) who present with chest pain or dyspnea to determine graft patency and severity of graft stenoses.
CCTA may be used in patients with prior intracoronary stents who present with recurrent chest pain to evaluate for in-stent restenosis, noting that assessment can be limited by stent-related artifact and scan quality.

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

J15

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

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

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.