Does C79.40 require prior authorization?

No, C79.40 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`C79.40`, Secondary malignant neoplasm of unspecified part of nervous system

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The patient's medical record must contain documentation that fully supports medical necessity for services included in the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Include a treatment prescription that defines treatment goals and specific dose-volume parameters for the target and nearby critical structures, and details of beam delivery such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
Include a physician-signed treatment plan that meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) accounting for expected uncertainties.

Key Coverage Criteria

Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.
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).
Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
Stereotactic radiosurgery (SRS) is typically furnished as a single session; when more than one session is required, bill using stereotactic body radiation therapy (SBRT) codes instead of SRS codes.
Coverage on an individual (redetermination/appeal) basis may be considered for lesions that require a high radiation dose per fraction to avoid exposure of surrounding tissues when documentation and supporting literature are provided.

20 Active Policies

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

J15

CGS-J15-L35442, MolDX: NRAS Genetic Testing

J15

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J18-L35906, Somatosensory Testing

J18

CGS-J18-L38584, MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells

J18

CGS-J18-L35442, MolDX: NRAS Genetic Testing

J18

WPS-J5-L36797, MolDX: NRAS Genetic Testing

A57581, Billing and Coding: MolDX: NRAS Genetic Testing

NGS-J6-L36850, Peripheral Nerve Blocks

NGS-J6-L37810, Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

A56827, Billing and Coding: Proton Beam Therapy

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

NGS-J6-L35076, Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

NGS-J6-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

A56867, Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

A56874, Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

A57452, Billing and Coding: Peripheral Nerve Blocks

NGS-J6-L35075, Proton Beam Therapy

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

`C79.40`, Secondary malignant neoplasm of unspecified part of nervous system

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

C79.40, Secondary malignant neoplasm of unspecified part of nervous system

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`C79.40`, Secondary malignant neoplasm of unspecified part of nervous system