Does Z85.53 require prior authorization?

No, Z85.53 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`Z85.53`, Personal history of malignant neoplasm of renal pelvis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.
For Part A and Part B submissions, follow the respective HCPCS coding guidance provided (codes differ by drug form, biosimilar, and effective dates); bill units consistent with the indicated HCPCS code descriptions.

Key Coverage Criteria

For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).

20 Active Policies

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-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J18

CGS-J18-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J18

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Use CPT codes 78472, 78473, 78481, 78483, 78494, or 78496 when billing cardiac blood pool imaging (MUGA, ventriculography).

When applicable, include the additional secondary code indicating personal history of malignant neoplasm (Z85 series) per Correct Coding Initiative (CCI) guidelines alongside the appropriate C-code or D-code family entry.

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L38835, MolDX: Minimal Residual Disease Testing for Cancer

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

A58468, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

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

A52370, Billing and Coding: Bevacizumab and biosimilars

WPS-J8-L38835, MolDX: Minimal Residual Disease Testing for Cancer

WPS-J8-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

A57450, Billing and Coding: Genetic Testing for Lynch Syndrome

FIRST_COAST-L34912, Genetic Testing for Lynch Syndrome

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

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

A54768, Billing and Coding: Cardiac Blood Pool Imaging (Multiple Gated Acquisition Scanning- MUGA, Ventriculography) When Performed in Conjunction with Cardiotoxic Chemotherapy

A58376, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

A58434, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

A58454, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

Z85.53, Personal history of malignant neoplasm of renal pelvis