Does C40.01 require prior authorization?

No, C40.01 does not require prior authorization (high confidence). Covered without prior authorization.

`C40.01`, Malignant neoplasm of scapula and long bones of right upper limb

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Document Hgb and/or Hct values to support initiation and maintenance of ESA therapy (including Hgb immediately prior to initiation for chemotherapy patients).
Before starting ESA therapy, consider, document, and correct reversible causes of anemia: iron deficiency, infection/inflammation, hematologic disease, hemolysis, vitamin deficiencies (folate/B12), blood loss, and aluminum intoxication.
For patients who may need iron supplementation during ESA therapy, document iron stores with transferrin saturation > 20% and/or serum ferritin > 100 ng/mL to guide supplementation.
For MDS patients document pretreatment erythropoietin level (≤ 500) and blast percentage (< 10%) prior to ESA initiation.

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-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J15

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

J15

CGS-J15-L36658, Proton Beam Therapy

J15

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

J15

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