Does Z85.3 require prior authorization?

No, Z85.3 does not require prior authorization (high confidence). Covered without prior authorization.

`Z85.3`, Personal history of malignant neoplasm of breast

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Submit the appropriate CPT code and one (1) unit of service for the test.
Include the assigned DEX Z‑Code™ identifier adjacent to the CPT code in the claim narrative/field (Part B: Loop 2400 or SV101-7 for 837P 5010A1; Part A: SV202-7 for 837I or Block 80 for UB04) or submit the Z‑Code on an attachment for paper claims.
Include at least one appropriate ICD‑10‑CM diagnosis code on the claim.
Medical records must support that the patient meets the clinical indication for immediate PARP inhibitor use, absence of prior relevant germline/somatic testing, and that comprehensive panel testing is not required per LCD L39040.

Germline testing is covered when the patient has ovarian, breast, pancreatic, or prostate cancer and meets clinical indication for immediate treatment with an FDA‑approved PARP inhibitor.
Testing for deleterious variants in homologous recombination repair (HRR) genes (e.g., BRCA1, BRCA2) is covered as an aid when results will be used to determine eligibility for PARP inhibitor therapy.
Limited germline testing of a select group of genes (rather than a comprehensive panel) is covered when the patient does not meet criteria for larger panel testing per LCD L39040 and limited testing is necessary to comply with FDA indicated drug usage.
Coverage applies only if the patient has had no prior germline hereditary cancer testing and no prior somatic testing of the same cancer that already included the genes required to assess PARP inhibitor eligibility.
Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.

CGS-J15-L38584, MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L33950, Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

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