Does C94.80 require prior authorization?

No, C94.80 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`C94.80`, Other specified leukemias not having achieved remission

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The medical record must document that the testing is expected to influence treatment of the condition for which the test is ordered and include an ordering physician/NPP requisition containing the relevant ICD-10-CM diagnosis code.
Ordering physician/NPP documentation should include history and physical or exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging) that support medical necessity.
Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.

Key Coverage Criteria

When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.
Use modifier 91 only when a test is performed more than once on the same day for the same patient and the repeat testing is necessary to obtain multiple results in the course of treatment.
Targeted genomic sequence analysis panels for hematolymphoid neoplasms (including acute myelogenous leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms) are covered when the panel contains at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and are consistent with NCCN recommendations.
Targeted genomic sequence analysis panels with 5–50 genes (CPT 81450 or 81451) or 51 or more genes (CPT 81455 or 81456) are represented by these CPT codes and may be used when the panel meets the minimum 5-gene and evidence requirements above.

20 Active Policies

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

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J18-L34037, Flow Cytometry

J18

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

J18

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

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

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

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

NGS-J6-L36850, Peripheral Nerve Blocks

NGS-J6-L37606, Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

NGS-J6-L35000, Molecular Pathology Procedures

A56199, Billing and Coding: Molecular Pathology Procedures

A57452, Billing and Coding: Peripheral Nerve Blocks

NGS-J6-L40357, Molecular Pathology Procedures

A56793, Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

WPS-J8-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J8-L38835, MolDX: Minimal Residual Disease Testing for Cancer

FIRST_COAST-L33933, Peripheral Nerve Blocks

NGS-JK-L37606, Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

NGS-JK-L40357, Molecular Pathology Procedures

`C94.80`, Other specified leukemias not having achieved remission

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

C94.80, Other specified leukemias not having achieved remission

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`C94.80`, Other specified leukemias not having achieved remission