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ICD-10-CM R97.1, Elevated cancer antigen 125 [CA 125] | No Prior Auth

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`R97.1`, Elevated cancer antigen 125 [CA 125]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

Key Coverage Criteria

CA-125 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:Appendiceal adenocarcinoma;orEndometrial cancer;orOvarian, primary peritoneal or fallopian tube cancer;orPancreatic adenocarcinoma;orPeritoneal mesothelioma;orUterine neoplasms (endometrial cancer and uterine sarcoma).
As part of initial evaluation for suspected or diagnosed disease;or
To determine whether residual tumor exists post-surgical therapy;and
Conditions:Appendiceal adenocarcinoma;orEndometrial cancer;orOvarian, primary peritoneal or fallopian tube cancer;orPancreatic adenocarcinoma;orPeritoneal mesothelioma;orUterine neoplasms (endometrial cancer and uterine sarcoma).
Appendiceal adenocarcinoma;or
Endometrial cancer;or

2 Active Policies

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

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

Related Codes

C45.1(2 policies)C51.8(2 policies)C25.0(2 policies)C25.9(2 policies)C48.0(2 policies)C48.8(2 policies)C18.1(2 policies)C53.0(2 policies)

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