Does D04.61 require prior authorization?

No, D04.61 does not require prior authorization (high confidence). Covered without prior authorization.

`D04.61`, Carcinoma in situ of skin of right upper limb, including shoulder

ICD-10-CM

No Prior Auth Required

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.
Recurrent basal cell carcinoma (BCC) of any size or an unexpected positive margin on recent excision is covered for MMS.
Primary aggressive BCC is covered with coverage for lesions ≤0.5 cm limited to Areas H and M (Area L would rarely be medically necessary) and lesions ≥0.6 cm covered in Areas H, M and L.
Primary nodular BCC (healthy patient) is covered for MMS for lesions ≤0.5–1.0 cm in Areas H and M only (no coverage for Area L), for 1.1–2.0 cm in Areas H and M (Area L would rarely be medically necessary), and for ≥2.0 cm in Areas H, M and L.

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

J15

CGS-J18-L40178, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J18

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