Does C81.12 require prior authorization?

No, C81.12 does not require prior authorization (high confidence). Covered without prior authorization.

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`C81.12`, Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Report the appropriate CPT code for the test being performed.
Enter 1 unit of service (UOS) for the reported CPT code.
Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for Part B electronic claims (Loop 2400 or SV101-7 for 5010A1 837P) and paper claims (Box 19).
Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for Part A electronic claims (Line SV202-7 for 837I) and UB04 claims (Block 80).

Key Coverage Criteria

Lab-developed tests for inherited cancer syndromes in patients with cancer as described in Local Coverage Determination (LCD) L39040 are the services addressed by this billing/coding guidance.
ClonoSeq (NGS-based MRD test) is covered for patients with acute lymphoblastic leukemia (ALL).
ClonoSeq (NGS-based MRD test) is covered for patients with multiple myeloma (MM).
ClonoSeq (NGS-based MRD test) is covered for patients with chronic lymphocytic leukemia (CLL).
ClonoSeq (NGS-based MRD test) is covered for patients with diffuse large B-cell lymphoma (DLBCL).
ClonoSeq (NGS-based MRD test) is covered for patients with mantle cell lymphoma.

20 Active Policies

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

J15

CGS-J15-L39434, Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

J15

CGS-J15-L34037, Flow Cytometry

J15

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

J15

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Select and report the appropriate ICD-10-CM diagnosis code(s) that support the medical necessity of the test.

Refer to Billing and Coding: MolDX: Testing of Multiple Genes (policy A57880) for guidance on single-gene and panel testing of genes.

CGS-J15-L36658, Proton Beam Therapy

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L39434, Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

J18

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

J18

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L36658, Proton Beam Therapy

J18

A59259, Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

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

WPS-J5-L39477, Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin

A59004, Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers

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

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

NGS-J6-L36850, Peripheral Nerve Blocks

C81.12, Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes