Does C84.16 require prior authorization?

No, C84.16 does not require prior authorization (high confidence). Covered without prior authorization.

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`C84.16`, Sezary disease, intrapelvic lymph nodes

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When a referring or ordering physician is required, the referring/ordering provider's name and NPI must be reported on the claim.
For diagnostic tests, report the test result on the claim if known; if the result is not known at time of billing, report the symptoms that prompted the test.
Diagnosis code(s) on the claim must best describe the patient's condition for which the Vitamin D assay was performed.
All services and procedures performed on the same day for the same beneficiary by the same physician/provider should be billed on the same claim (use appropriate claim form and fields per CMS guidance).

Key Coverage Criteria

Vitamin D assay testing is payable under Medicare Part B when performed in an office (POS 11), independent clinic (POS 49), Federally Qualified Health Center (POS 50), or independent laboratory (POS 81).
Non-physician practitioners (e.g., nurse practitioners, clinical nurse specialists, physician assistants) may certify, order, and establish the plan of care for Vitamin D assay testing as authorized by State law (outpatient settings other than CORFs).
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).

20 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

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

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-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

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C84.16, Sezary disease, intrapelvic lymph nodes