Does C7A.095 require prior authorization?

No, C7A.095 does not require prior authorization (high confidence). Covered without prior authorization.

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`C7A.095`, Malignant carcinoid tumor of the midgut, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The performing provider must maintain medical record documentation that clearly supports the medical necessity of the billed service and include that documentation in the patient's record for review upon request.
Documentation should state whether the block was diagnostic or therapeutic, include pre- and post-procedure evaluations, and document patient education and the assessment of procedural outcome.
Documentation must support coverage criteria in the LCD 'Indications and Limitations of Coverage and/or Medical Necessity' section and the provider should document why services cannot be rendered by the surgeon when applicable.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.

Key Coverage Criteria

CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
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).

20 Active Policies

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

J15

CGS-J15-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J15

CGS-J15-L38067, MolDX: Next-Generation Sequencing for Solid Tumors

J15

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

J15

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C7A.095, Malignant carcinoid tumor of the midgut, unspecified