Does C44.691 require prior authorization?

No, C44.691 does not require prior authorization (high confidence). Covered without prior authorization.

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`C44.691`, Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient's medical record must contain documentation that fully supports medical necessity for services included in the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Include a treatment prescription that defines treatment goals and specific dose-volume parameters for the target and nearby critical structures, and details of beam delivery such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
Include a physician-signed treatment plan that meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) accounting for expected uncertainties.

Key Coverage Criteria

Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.
Coverage is allowed for targeted genomic sequence analysis panels for treatment of solid organ neoplasms when the panel is a DNA analysis panel containing at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria.
Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).
Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
Initial MRD testing is covered for patients with cancer when baseline tumor profiling from a prior analysis is utilized, using listed bespoke/plasma-series MRD tests (e.g., Signatera Bespoke Assay Design + Plasma Series Bundle, RaDaR Bespoke Assay Design + Plasma Series Bundle, Oncodetect Bespoke Assay Design + Plasma Test Bundle, Guardant Reveal MRD Bundle, Guardant360 Response).
Subsequent MRD testing for patients with cancer is covered only if there is clinical evidence of an a priori change in tumor genetic content in accordance with NCD 90.2.

20 Active Policies

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

J15

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

J15

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

J15

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

J15

CGS-J18-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J18

CGS-J18-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J18

CGS-J18-L38067, MolDX: Next-Generation Sequencing for Solid Tumors

J18

CGS-J18-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J18

WPS-J5-L40277, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

A57858, Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors

A58468, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L38835, MolDX: Minimal Residual Disease Testing for Cancer

WPS-J5-L38158, MolDX: Next-Generation Sequencing for Solid Tumors

A56827, Billing and Coding: Proton Beam Therapy

A56867, Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

NGS-J6-L37810, Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

NGS-J6-L35075, Proton Beam Therapy

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

`C44.691`, Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

C44.691, Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`C44.691`, Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder