Does C94.81 require prior authorization?

No, C94.81 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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`C94.81`, Other specified leukemias, in 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

For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
Diagnostic test claims should include the test result if known; if result is not available, report the symptoms that prompted the test.
The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
When using an Advance Beneficiary Notice of Non‑coverage (ABN) with modifier GA, the ABN Form CMS‑R‑131 must be signed by the beneficiary (or properly witnessed if refused) and Part A MAC claims require occurrence code 32 plus the ABN date.

Key Coverage Criteria

CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.
Flow cytometry interpretation is reported using CPT codes 88187–88189 (one interpretation code per specimen).
Quantitative cell counts by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361, and 86367.
Flow cytometry services are payable under Medicare Part B at specified places of service according to CPT: groups of CPTs have defined allowable POS (see mapping in policy).
Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.

20 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

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

J15

CGS-J18-L34037, Flow Cytometry

J18

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

J18

A59004

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C94.81, Other specified leukemias, in remission