Does C7A.8 require prior authorization?

No, C7A.8 does not require prior authorization (high confidence). Covered without prior authorization.

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`C7A.8`, Other malignant neuroendocrine tumors

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.
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.
Colonoscopy is covered for investigation of a positive fecal occult blood test.
Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.

20 Active Policies

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

J15

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

J15

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

J15

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

J15

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Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part A claims (Line SV202-7 for 837I electronic claims; Block 80 for UB04 paper claims).

Select and report an appropriate ICD-10-CM diagnosis code on the claim that supports the medical necessity for the test.

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

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L36975, Bladder/Urothelial Tumor Markers

J15

CGS-J18-L38067, MolDX: Next-Generation Sequencing for Solid Tumors

J18

CGS-J18-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J18

CGS-J18-L36975, Bladder/Urothelial Tumor Markers

J18

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

J18

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J18

CGS-J18-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J18

CGS-J18-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J18

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L36807, MolDX: Molecular Diagnostic Tests (MDT)

WPS-J5-L38158, MolDX: Next-Generation Sequencing for Solid Tumors

WPS-J5-L38835, MolDX: Minimal Residual Disease Testing for Cancer

WPS-J5-L40277, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

A55147, Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update

C7A.8, Other malignant neuroendocrine tumors