Does R97.0 require prior authorization?

No, R97.0 does not require prior authorization (high confidence). Covered without prior authorization.

`R97.0`, Elevated carcinoembryonic antigen [CEA]

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.

CEA testing is consideredmedically necessaryforeitherclinical scenario (AorB)andthe following conditions (C):As part of initial evaluation for suspected or diagnosed disease;orTo determine whether residual tumor exists post-surgical therapy;andConditions:Ampullary adenocarcinoma;orAppendiceal adenocarcinoma;orBiliary tract cancer (gallbladder, cholangiocarcinoma);orColorectal cancer;orMalignant pleural mesothelioma;orMedullary thyroid carcinoma;orMetastatic breast cancer;orMultiple Endocrine Neo [...]
As part of initial evaluation for suspected or diagnosed disease;or
To determine whether residual tumor exists post-surgical therapy;and
Conditions:Ampullary adenocarcinoma;orAppendiceal adenocarcinoma;orBiliary tract cancer (gallbladder, cholangiocarcinoma);orColorectal cancer;orMalignant pleural mesothelioma;orMedullary thyroid carcinoma;orMetastatic breast cancer;orMultiple Endocrine Neoplasia Type 2 (MEN2);orOvarian, primary peritoneal, or fallopian tube cancer;orPancreatic neoplasms;orRectal cancer;orSmall bowel adenocarcinoma (duodenum, jejunum, ileum).
Ampullary adenocarcinoma;or
Appendiceal adenocarcinoma;or

ANTHEM-CG-LAB-33, Carcinoembryonic Antigen Testing

ANTHEM-CG-LAB-32, Cancer Antigen 125 Testing

A56421, Billing and Coding: CT of the Abdomen and Pelvis

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