Does C81.17 require prior authorization?

No, C81.17 does not require prior authorization (high confidence). Covered without prior authorization.

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`C81.17`, Nodular sclerosis Hodgkin lymphoma, spleen

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-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-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

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

J15

CGS-J15-L34037, Flow Cytometry

J15

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C81.17, Nodular sclerosis Hodgkin lymphoma, spleen