Does C85.95 require prior authorization?

No, C85.95 does not require prior authorization (high confidence). Covered without prior authorization.

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`C85.95`, Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Select and report the appropriate CPT or PLA code for the blood product molecular antigen typing service and enter the unit of service (UOS) on the claim.
For Part B claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT/PLA code in the comment/narrative field: use Loop 2400 or SV101-7 for 5010A1 837P electronic claims or Box 19 for paper claims.
For Part A claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT/PLA code in the comment/narrative field: use Line SV202-7 for 837I electronic claims or Block 80 for the UB04 claim form.

Include the appropriate ICD-10-CM diagnosis code on the claim when reporting the blood product molecular antigen typing service.

Report the appropriate CPT code for the test being performed.

Enter 1 unit of service (UOS) for the reported CPT code.

Key Coverage Criteria

MolDX blood product molecular antigen typing panels 0001U and 0084U (germline tests) are covered for beneficiaries but are limited to one test per beneficiary lifetime.
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-L38249, MolDX: Blood Product Molecular Antigen Typing

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-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-L38249, MolDX: Blood Product Molecular Antigen Typing

J18

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

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-L38441, MolDX: Blood Product Molecular Antigen Typing

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

A57110, Billing and Coding: MolDX: Blood Product Molecular Antigen Typing

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

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C85.95, Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb