Does C78.00 require prior authorization?

No, C78.00 does not require prior authorization (high confidence). Covered without prior authorization.

`C78.00`, Secondary malignant neoplasm of unspecified lung

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.
Use CPT code 81540 on the claim when billing for Cancer TYPE ID.

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
Coverage is allowed for targeted genomic sequence analysis panels for treatment of solid organ neoplasms when the panel is a DNA analysis panel containing at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria.
Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).

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

J15

CGS-J15-L35442, MolDX: NRAS Genetic Testing

J15

CGS-J15-L38584, MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells

J15

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

J18

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