Does C49.9 require prior authorization?

No, C49.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`C49.9`, Malignant neoplasm of connective and soft tissue, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Use CPT code 81540 on the claim when billing for Cancer TYPE ID.
Enter '1' in the Days/Unit field on the claim for this test.
Submit the required test identifier information using SV101-7 or SV202-7 (SV202-7 preferred) or via the NTE field if needed.
Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part B claims (Loop 2400 or SV101-7 for 5010A1 837P; Box 19 for paper claims).

Key Coverage Criteria

Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
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.

20 Active Policies

CGS-J15-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J15

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

J15

CGS-J15-L34037, Flow Cytometry

J15

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

J15

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Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part A claims (Line SV202-7 for 837I electronic claims; Block 80 for UB04 paper claims).

Select and report an appropriate ICD-10-CM diagnosis code on the claim that supports the medical necessity for the test.

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

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

J15

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

J15

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

J18

CGS-J18-L34037, Flow Cytometry

J18

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

J18

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

J18

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

J18

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

J18

CGS-J18-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J18

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

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

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

WPS-J5-L36807, MolDX: Molecular Diagnostic Tests (MDT)

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

A55147, Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update

C49.9, Malignant neoplasm of connective and soft tissue, unspecified