Does C64.9 require prior authorization?

No, C64.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`C64.9`, Malignant neoplasm of unspecified kidney, except renal pelvis

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.
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).
Subsequent MRD testing for patients without cancer is covered as specified for listed single-plasma recurrence-monitoring tests (e.g., Signatera Recurrence Monitoring single Plasma Test, RaDaR Recurrence Monitoring single Plasma Test, Oncodetect single Plasma Test, Pathlight Recurrence Monitoring single Plasma Test).
Tumor‑naïve MRD testing (baseline tumor profiling not utilized) is covered for specified single-plasma tests (e.g., NavDX single Plasma Test, Guardant Reveal single Plasma Test).

20 Active Policies

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

J15

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

J15

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

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

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C64.9, Malignant neoplasm of unspecified kidney, except renal pelvis