Does D72.821 require prior authorization?

No, D72.821 does not require prior authorization (high confidence). Covered without prior authorization.

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`D72.821`, Monocytosis (symptomatic)

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
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.

Key Coverage Criteria

Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
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.

20 Active Policies

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

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J18-L38070, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J18

CGS-J18-L34037, Flow Cytometry

J18

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Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.

For laboratory-developed tests (LDTs)/protocols, documentation must include the diagnostic test/assay, lab/manufacturer, comparable assays (if relevant), assay description, analytical validity, clinical validity, and clinical utility.

A57878, Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

WPS-J5-L38176, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

NGS-J6-L37606, Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

NGS-J6-L35000, Molecular Pathology Procedures

A56199, Billing and Coding: Molecular Pathology Procedures

NGS-J6-L40357, Molecular Pathology Procedures

A56793, Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

WPS-J8-L38176, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

NGS-JK-L40357, Molecular Pathology Procedures

NGS-JK-L35000, Molecular Pathology Procedures

NGS-JK-L37606, Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

A57837, Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

A57873, Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

A55717, Billing and Coding: Lab: Flow Cytometry

A57891, Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

A56464, Billing and Coding: Flow Cytometry

D72.821, Monocytosis (symptomatic)