Does C84.97 require prior authorization?

No, C84.97 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`C84.97`, Mature T/NK-cell lymphomas, unspecified, spleen

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is 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.
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.
Allogeneic hematopoietic cell transplantation (HCT) is covered for beneficiaries with primary refractory Hodgkin lymphoma when coverage criteria of CMS NCD 110.23 and local LCD L39477 are met.
Allogeneic HCT is covered for beneficiaries with relapsed Hodgkin lymphoma when coverage criteria of CMS NCD 110.23 and local LCD L39477 are met.
Allogeneic HCT is covered for beneficiaries with primary refractory or relapsed Non-Hodgkin lymphoma of B-cell origin when coverage criteria of CMS NCD 110.23 and local LCD L39477 are met.
Allogeneic HCT is covered for beneficiaries with primary refractory or relapsed Non-Hodgkin lymphoma of T-cell origin when coverage criteria of CMS NCD 110.23 and local LCD L39477 are met.

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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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-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J15

CGS-J18-L34037, Flow Cytometry

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-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J18

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

J18

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

J18

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

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

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

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

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

NGS-J6-L39513, Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin

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

NGS-J6-L36850, Peripheral Nerve Blocks

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

C84.97, Mature T/NK-cell lymphomas, unspecified, spleen