Does R97.21 require prior authorization?

No, R97.21 does not require prior authorization (high confidence). Covered without prior authorization.

`R97.21`, Rising PSA following treatment for malignant neoplasm of prostate

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The supplier must enter a diagnosis code corresponding to the beneficiary's cancer diagnosis on each claim for oral antiemetic drugs.
A written, signed, and dated order must be received by the supplier before a claim is submitted for any oral antiemetic drug.
Claims for oral aprepitant (J8501), rolapitant (J8670) or netupitant/palonosetron (J8655) must also be accompanied by a diagnosis code indicating an encounter for antineoplastic chemotherapy.
Claims billed for code Q0181 must include drug name, manufacturer, dosage strength dispensed, each tablet/suppository/etc, and frequency of administration during the covered time period entered in the narrative field of an electronic claim.

An oral antiemetic drug is covered when it has been ordered by the treating practitioner as part of a cancer chemotherapy regimen.
An oral antiemetic drug is covered when the drug is FDA‑approved for use as an antiemetic.
An oral antiemetic drug is covered when it is used as a full therapeutic replacement for an intravenous antiemetic that would otherwise have been administered at the time of the chemotherapy treatment.
An oral antiemetic drug is covered when it is initiated within two hours of administration of the chemotherapeutic agent and continued no more than 48 hours from that time.
A 3‑drug regimen (NK‑1 antagonist + 5HT3 antagonist + dexamethasone) is covered when all four coverage criteria are met and all three drugs are given in combination.
Netupitant/palonosetron (fixed combination) is covered when given in conjunction with dexamethasone without requiring a separate 5HT3 antagonist, provided the general coverage criteria are met.

NGS-J6-L33578, Transrectal Ultrasound

A57427, Billing and Coding: Transrectal Ultrasound

NGS-JK-L33578, Transrectal Ultrasound

AETNA-CPB-0521, Prostate Cancer Screening

A52480, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article

Ask Backwork about documentation requirements, denial risks, or coverage in your state.