Does C4A.71 require prior authorization?

No, C4A.71 does not require prior authorization (high confidence). Covered without prior authorization.

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`C4A.71`, Merkel cell carcinoma of right lower limb, including hip

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.
Mohs micrographic surgery is covered for basal cell carcinoma located in the mask area of the face (central face, eyelids, eyebrows, periorbital areas, nose, lips, chin, mandible, periauricular areas, ear, temple, sulci).
Mohs micrographic surgery is covered for basal cell, squamous cell, or basalosquamous cell carcinomas on the forehead, cheeks, or neck.
Mohs micrographic surgery is covered for basal cell, squamous cell, or basalosquamous cell carcinomas of the genitalia.
Mohs micrographic surgery is covered for basal cell, squamous cell, or basalosquamous cell carcinomas of the hands or feet.
Mohs micrographic surgery is covered for basal cell, squamous cell, or basalosquamous cell carcinomas of the scalp.

20 Active Policies

CGS-J15-L34195, Mohs Micrographic Surgery

J15

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

J15

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

J15

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

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

J15

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

J18

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

J18

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

J18

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

J18

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

J18

CGS-J18-L34195, Mohs Micrographic Surgery

J18

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

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

WPS-J5-L35494, Mohs Micrographic Surgery

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

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

WPS-J5-L38168, MolDX: Plasma-Based Genomic Profiling in Solid Tumors

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

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

C4A.71, Merkel cell carcinoma of right lower limb, including hip