Does D38.1 require prior authorization?

No, D38.1 does not require prior authorization (high confidence). Covered without prior authorization.

`D38.1`, Neoplasm of uncertain behavior of trachea, bronchus and lung

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Use CPT code 81540 on the claim when billing for Cancer TYPE ID.
Enter '1' in the Days/Unit field on the claim for this test.
Submit the required test identifier information using SV101-7 or SV202-7 (SV202-7 preferred) or via the NTE field if needed.
Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part B claims (Loop 2400 or SV101-7 for 5010A1 837P; Box 19 for paper claims).

Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
Peripheral nerve blocks are covered when they meet the reasonable and necessary requirements specified in LCD L33933.
Molecular diagnostic tests (MDTs) that have completed MolDX registration and a technical assessment (TA) and that demonstrate analytical validity, clinical validity, and clinical utility meeting Medicare's reasonable and necessary criteria are covered.
This policy applies to and may cover: non–FDA-approved laboratory-developed tests (LDTs), modified FDA-approved/cleared kits/assays, tests billed with more than one HIPAA-compliant code, and tests meeting those descriptions billed with a Not Otherwise Classified (NOC) code, provided they meet MolDX registration/TA and reasonable-and-necessary requirements.

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L36021, MolDX: Molecular Diagnostic Tests (MDT)

J15

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

J15

CGS-J18-L34037

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