Does D37.4 require prior authorization?

No, D37.4 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D37.4`, Neoplasm of uncertain behavior of colon

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.
For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).

Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L40386

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