Does D47.4 require prior authorization?

No, D47.4 does not require prior authorization (high confidence). Covered without prior authorization.

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`D47.4`, Osteomyelofibrosis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For services requiring a referring/ordering physician, the claim must report the referring/ordering physician's name and NPI.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the genomic sequencing service was performed.
Documentation should support that the panel's biomarkers meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and demonstrate associated clinical utility.
Laboratories and clinicians including non‑NCCN genes in panels are advised to adhere to regulatory and institutional oversight mechanisms to document clinical validity and utility.

Key Coverage Criteria

Targeted genomic sequence analysis panels for hematolymphoid neoplasms (including acute myelogenous leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms) are covered when the panel contains at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and are consistent with NCCN recommendations.
Targeted genomic sequence analysis panels with 5–50 genes (CPT 81450 or 81451) or 51 or more genes (CPT 81455 or 81456) are represented by these CPT codes and may be used when the panel meets the minimum 5-gene and evidence requirements above.
Minimal residual disease (MRD) testing in myelodysplastic syndromes (MDS) for single-gene tests may be covered when the test is medically reasonable and necessary for the individual patient's care.
ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.

20 Active Policies

CGS-J15-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J15

CGS-J15-L40000, MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J15

CGS-J15-L38070, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J15

CGS-J15-L34037, Flow Cytometry

J15

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D47.4, Osteomyelofibrosis