Does C49.A4 require prior authorization?

No, C49.A4 does not require prior authorization (high confidence). Covered without prior authorization.

`C49.A4`, Gastrointestinal stromal tumor of large intestine

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
Select and report the appropriate CPT code for the Next-Generation Sequencing for Solid Tumors service.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
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.
Initial MRD testing is covered for patients without current cancer (per policy definition) when baseline tumor profiling from a prior analysis is utilized, using listed recurrence-monitoring bespoke + single-plasma tests (e.g., Signatera Recurrence Monitoring Bespoke Assay Design + single Plasma Test, RaDaR Recurrence Monitoring, Oncodetect Bespoke Assay, Pathlight Recurrence Monitoring).

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

J15

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

J15

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

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