Does D48.19 require prior authorization?

No, D48.19 does not require prior authorization (high confidence). Covered without prior authorization.

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`D48.19`, Other specified neoplasm of uncertain behavior of connective and other soft tissue

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The medical record must document that the testing is expected to influence treatment of the condition for which the test is ordered and include an ordering physician/NPP requisition containing the relevant ICD-10-CM diagnosis code.
Ordering physician/NPP documentation should include history and physical or exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging) that support medical necessity.
Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.

Key Coverage Criteria

When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.
Use modifier 91 only when a test is performed more than once on the same day for the same patient and the repeat testing is necessary to obtain multiple results in the course of treatment.
Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.

20 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

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

J15

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

J15

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

A56787, Billing and Coding: Nonvascular Extremity Ultrasound

NGS-J6-L33619, Nonvascular Extremity Ultrasound

NGS-J6-L35000, Molecular Pathology Procedures

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

NGS-J6-L40357, Molecular Pathology Procedures

A56199, Billing and Coding: Molecular Pathology Procedures

FIRST_COAST-L33933, Peripheral Nerve Blocks

NOVITAS-JH-L35396, Biomarkers for Oncology

NGS-JK-L35000, Molecular Pathology Procedures

NGS-JK-L33619, Nonvascular Extremity Ultrasound

NGS-JK-L40333, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40357, Molecular Pathology Procedures

`D48.19`, Other specified neoplasm of uncertain behavior of connective and other soft tissue

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

D48.19, Other specified neoplasm of uncertain behavior of connective and other soft tissue

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`D48.19`, Other specified neoplasm of uncertain behavior of connective and other soft tissue