Does D16.5 require prior authorization?

No, D16.5 does not require prior authorization (high confidence). Covered without prior authorization.

`D16.5`, Benign neoplasm of lower jaw bone

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.
Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.
Submitted medical record must support the use of the selected diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, ongoing documentation of any changes in course of treatment, and DHV as noted in the covered indications section.

Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy.
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).

CGS-J15-L36658, Proton Beam Therapy

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L36658, Proton Beam Therapy

J18

A57452, Billing and Coding: Peripheral Nerve Blocks

Ask Backwork about documentation requirements, denial risks, or coverage in your state.