Does Z79.818 require prior authorization?

No, Z79.818 does not require prior authorization (high confidence). Covered without prior authorization.

`Z79.818`, Long term (current) use of other agents affecting estrogen receptors and estrogen levels

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

For management of hypercalcemia of malignancy document ICD-10-CM code E83.52, the related malignancy, and the rationale for denosumab use.
Medical record must contain documentation that fully supports the medical necessity for administration of the specific denosumab formulation used.
For postmenopausal osteoporosis include menopausal status (female), age and sex, documentation supporting the osteoporosis diagnosis, prior osteoporosis treatments and outcomes/adverse reactions, prior fracture history (type, cause, time), and fracture risk factors/preventive measures.

Denosumab is covered for postmenopausal osteoporosis in patients at high risk for fracture when medical record documents menopausal status, diagnosis of osteoporosis, prior osteoporosis treatments and outcomes, fracture history, and fracture risk factors.
Denosumab is covered for cancer treatment–induced bone loss (CTIBL) in patients with breast cancer receiving adjuvant aromatase inhibitors (AI) or in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT) when documentation supports the cancer diagnosis and therapy.
Denosumab is covered for treatment of bone metastasis from a solid tumor when the claim lists bone metastasis (ICD-10-CM C79.51) as the primary diagnosis and the original cancer or history of cancer is included as the secondary diagnosis.
Denosumab is covered for management of hypercalcemia of malignancy when ICD-10-CM code E83.52 and the related malignancy and clinical rationale are documented.
Denosumab (Xgeva®) is covered for treatment of skeletal-related events in patients with multiple myeloma per FDA approval effective 01/04/2018 when clinical rationale is documented.
Coverage requires that the patient be adequately supplemented with calcium (1000 mg daily) and vitamin D (at least 400 IU daily) and that hypocalcemia be corrected prior to initiation of denosumab.

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

A57736, Billing and Coding: Vitamin D Assay Testing

A52399, Billing and Coding: Denosumab (Prolia, Xgeva, Jubbonti, Wyost, Ospomyv,Xbryk,Bomyntra, Conexxence, Stoboclo, Osenvelt,Bildyos, Bilprevda)

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

NGS-J6-L37535, Vitamin D Assay Testing

NGS-JK-L37535, Vitamin D Assay Testing

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

ANTHEM-CG-LAB-28, Prostate Specific Antigen Testing

A57132, Billing and Coding: Bone Mass Measurement

A57718, Billing and Coding: Vitamin D Assay Testing

ANTHEM-CG-SURG-88, Mastectomy for Gynecomastia

A59040, Billing and Coding: Bone Mass Measurement

A59170, Billing and Coding: Vitamin D Assay Testing