Does C85.17 require prior authorization?

No, C85.17 does not require prior authorization (high confidence). Covered without prior authorization.

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`C85.17`, Unspecified B-cell lymphoma, spleen

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.
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).

20 Active Policies

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

J15

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

J15

CGS-J15-L34037, Flow Cytometry

J15

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

J15

CGS-J15-L36021

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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.

, MolDX: Molecular Diagnostic Tests (MDT)

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-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-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

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

J18

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

J18

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

J18

CGS-J18-L34037, Flow Cytometry

J18

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

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

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

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

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

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

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

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

C85.17, Unspecified B-cell lymphoma, spleen