Does C9150 require prior authorization?

No, C9150 does not require prior authorization (high confidence). Covered without prior authorization.

`C9150`, Xenon xe-129 hyperpolarized gas, diagnostic, per study dose

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation of the covered indication: diagnosis and clinical scenario placing member in one of the covered groups (known/prior lung cancer; suspected lung cancer with supporting clinical symptoms such as positive sputum cytology, hemoptysis, unresolved pneumonia, persistent cough, or positive chest X-ray; or prior resected Stage I lung cancer with no metastatic disease at risk for secondary disease)
Documentation that LIFE will be performed in conjunction with white-light bronchoscopy (WLB) and using the appropriate equipment (policy states Olympus BF-20D flexible fiber optic bronchoscope is indicated)
Documentation that the treating physician has appropriate training in flexible fiber optic bronchoscopy and training in the use of the LIFE device (per federal restriction noted)

Lung imaging fluorescence endoscopy (LIFE) is medically necessary to enhance the physician's ability to detect and biopsy abnormal bronchial tissue suspicious for pre-cancerous lesions, carcinomas in-situ, and early bronchogenic carcinomas in any of the following groups:
Members with known or previously diagnosed lung cancer
Members with suspected lung cancer, including members suspected because of clinical symptoms such as positive sputum cytology, hemoptysis, unresolved pneumonia, persistent cough, or positive chest X-ray
Members with a previously resected Stage I lung cancer, with no evidence of metastatic disease, who are at risk for secondary disease
Use of bronchoscopy CPT codes related to the procedure when clinically indicated (listed CPTs 31622, 31623, 31624, 31625, 31628, 31629, 31630, 31631, 31632, 31633, 31635, 31636, 31637, 31638, 31640) when used in appropriate clinical context described above
Use of ICD-10 diagnoses listed as 'covered if selection criteria are met' when patient meets the stated clinical selection criteria: C34.00–C34.92 (malignant neoplasm of bronchus and lung); C78.00–C78.02 (secondary malignant neoplasm of lung); D02.20–D02.22 (carcinoma in situ of bronchus and lung); D14.30–D14.32 (benign neoplasm of bronchus and lung); D38.1 (neoplasm of uncertain behavior of trachea, bronchus, and lung); J10.00–J10.08, J11.00–J11.08, J12.0–J18.1, J18.8–J18.9 (pneumonia codes); R [...]

AETNA-CPB-0581, Lung Imaging: Selected Techniques

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