Does Z85.51 require prior authorization?

No, Z85.51 does not require prior authorization (high confidence). Covered without prior authorization.

`Z85.51`, Personal history of malignant neoplasm of bladder

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.
For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).

Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered when performed on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder cancer using urine specimens.
Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.

CGS-J15-L36975, Bladder/Urothelial Tumor Markers

J15

CGS-J15-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J15

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

J15

CGS-J18-L36975, Bladder/Urothelial Tumor Markers

J18

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