Does M1A.0511 require prior authorization?

No, M1A.0511 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M1A.0511`, Idiopathic chronic gout, right hip, with tophus (tophi)

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

When billing Part B claims, include the drug(s) being considered that require the PGx test on the applicable detail line (eg, 2400 loop on 837P); for Part A include Loop SV202-7 (837I) or Block 80 (UB04); for paper Part B include Box 19.
When billing CPT 81418, list the names of all specific genes tested (in addition to CYP2C19 and CYP2D6) in the claim comment/narrative field appropriate to the claim type (Part A SV202-7/Block80; Part B Loop 2400/SV101-7/Box19).
Document prior germline testing history and the clinical rationale or evidence of established clinical utility for any non-duplicative components to support that the service billed is reasonable and necessary.

Key Coverage Criteria

Pharmacogenomics (PGx) testing is covered when it is reasonable and necessary per LCD L39063 and Medicare coverage rules for the beneficiary's clinical indication.
CPT 81418 (PGx multi-gene panel) is covered when the test assays at least 6 genes, including CYP2C19 and CYP2D6 and CYP2D6 duplication/deletion analysis, and the panel is clinically indicated to guide drug therapy.
A clinician-ordered single gene or allele test is considered covered when the billed component corresponds to the single gene/allele that was reasonable and necessary, even if the laboratory platform concurrently interrogated other genes operationally.
Germline testing panels that include some previously tested genetic content may be covered if there is established clinical utility for the remaining non-duplicative genetic components of the panel.
Genes may be assayed serially or in parallel; additional gene analyses done after a reflex decision are covered when those reflexive analyses are reasonable and necessary for the beneficiary's care.
Germline pharmacogenomic (PGx) testing is covered when the test results have established clinical utility to guide management of a specific drug therapy for the Medicare beneficiary.

14 Active Policies

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-J6-L39995, Pharmacogenomic Testing

A59915, Billing and Coding: Pharmacogenomic Testing

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

FIRST_COAST-L39073, Pharmacogenomics Testing

A58812, Billing and Coding: Pharmacogenomics Testing

NOVITAS-JH-L39063, Pharmacogenomics Testing

NGS-JK-L39995, Pharmacogenomic Testing

A58801, Billing and Coding: Pharmacogenomics Testing

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NOVITAS-JL-L39063, Pharmacogenomics Testing

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

`M1A.0511`, Idiopathic chronic gout, right hip, with tophus (tophi)

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

M1A.0511, Idiopathic chronic gout, right hip, with tophus (tophi)

Prior Authorization

Documentation Required

Key Coverage Criteria

14 Active Policies

Related Codes

Have a follow-up question?

`M1A.0511`, Idiopathic chronic gout, right hip, with tophus (tophi)