Does D04.5 require prior authorization?

No, D04.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D04.5`, Carcinoma in situ of skin of trunk

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Operative notes and pathology documentation must clearly show that Mohs was performed using accepted technique and that the surgeon acted in both surgical and pathology capacities.
Medical record must document location, number, and size of lesion(s); number of stages performed; and number of specimens per stage.
Histology documentation must include for the first stage: presence of tumor, depth of invasion, pathological pattern, cell morphology, and perineural invasion if present; subsequent stages must note if characteristics are same or describe differences.
Documentation must explain why the lesion will not be or was not managed by standard excision or destruction, and when applicable justify the selection of complex repair techniques (adjacent tissue transfer, flap, graft) or referral to plastic surgery.

Mohs micrographic surgery is covered when selected because the lesion's complexity (e.g., poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), size, or anatomic location requires maximal tissue conservation and other approaches (standard excision or destruction) are not medically reasonable or necessary.
Mohs surgery is considered covered when the surgeon performs both the surgical excision and the pathologic examination (surgeon acting in integrated surgical and pathology roles) as part of the Mohs technique.
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.
Reconstructive surgery is covered for abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease when performed to improve function or approximate normal appearance.
Removal of breast implant(s) is covered when the medical record documents a condition that makes removal medically reasonable and necessary.
Breast reduction (reduction mammoplasty) is covered when clinical evaluation documents macromastia with signs/symptoms, height/weight and BSA are recorded, and back/neck/shoulder pain is unrelieved by at least 6 months of conservative treatment, with operative and pathology reports documenting the weight of tissue removed from each breast.

CGS-J15-L34195, Mohs Micrographic Surgery

J15

CGS-J15-L40178, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J15

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

CGS-J15-L40179, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J15

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