Does C78.5 require prior authorization?

No, C78.5 does not require prior authorization (high confidence). Covered without prior authorization.

`C78.5`, Secondary malignant neoplasm of large intestine and rectum

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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).

Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
therascreen® KRAS test: detection of somatic KRAS mutations to identify colorectal cancer (CRC) patients for treatment with cetuximab (Erbitux®).
cobas® KRAS test: detection of KRAS mutations in codons 12 and 13 to identify colorectal cancer (CRC) patients for treatment with cetuximab (Erbitux®) or panitumumab (Vectibix®).
Evaluation of an anorectal adenomatous polyp is covered (adenomatous polyps only).
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.

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

J15

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

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

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

J15

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