Does D64.81 require prior authorization?

No, D64.81 does not require prior authorization (high confidence). Covered without prior authorization.

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`D64.81`, Anemia due to antineoplastic chemotherapy

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 referring/ordering physician's name and NPI must be reported on the claim.
Diagnostic test claims should include the test result if known; if result is not available, report the symptoms that prompted the test.
The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
When using an Advance Beneficiary Notice of Non‑coverage (ABN) with modifier GA, the ABN Form CMS‑R‑131 must be signed by the beneficiary (or properly witnessed if refused) and Part A MAC claims require occurrence code 32 plus the ABN date.

Key Coverage Criteria

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).
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).

19 Active Policies

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J18

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Use modifier GX when a voluntary ABN was signed and denial is anticipated for reasons other than medical necessity; use modifier GZ when denial is expected and no ABN is signed; use modifier GY for statutorily non‑covered services (no ABN required).

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.

WPS-J5-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A58761, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58963, Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

NGS-J6-L39226, Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

WPS-J8-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

NGS-JK-L39226, Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

AMBETTER-CP.MP.209, Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

A58720, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58747, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58710, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

AMBETTER-CP.MP.181, Polymerase Chain Reaction Respiratory Viral Panel Testing

A56464, Billing and Coding: Flow Cytometry

D64.81, Anemia due to antineoplastic chemotherapy