Does C49.21 require prior authorization?

No, C49.21 does not require prior authorization (high confidence). Covered without prior authorization.

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`C49.21`, Malignant neoplasm of connective and soft tissue of right lower limb, including hip

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

Documentation must demonstrate that the physician performing Mohs micrographic surgery furnished both the surgical and the histologic (pathologic) evaluation of the specimen(s).

When a denial is likely based on medical necessity or other coverage reasons, the provider/supplier must notify the beneficiary in writing prior to rendering the service.

Key Coverage Criteria

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.

20 Active Policies

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

J15

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

J15

CGS-J15-L34195, Mohs Micrographic Surgery

J15

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

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L36658, Proton Beam Therapy

J15

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

J15

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

J15

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

J15

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L40232, Total Joint Arthroplasty

J18

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

J18

CGS-J18-L34195, Mohs Micrographic Surgery

J18

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

J18

CGS-J18-L36658, Proton Beam Therapy

J18

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

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

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

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C49.21, Malignant neoplasm of connective and soft tissue of right lower limb, including hip