Does 0004M require prior authorization?

No, 0004M does not require prior authorization (high confidence). Code is covered without prior authorization.

`0004M`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Report the appropriate CPT code for the Molecular Diagnostic Test on the claim.
Enter 1 unit of service (UOS) for the Molecular Diagnostic Test line item on the claim.
For Part B electronic 837P claims, place the appropriate DEX Z-Code identifier adjacent to the CPT code in Loop 2400 or in the SV101-7 comment/narrative field.
For Part B paper claims, place the appropriate DEX Z-Code identifier adjacent to the CPT code in Box 19.

Coverage for repeat germline testing is determined by the referenced Local Coverage Determination MolDX: Repeat Germline Testing L38429; consult that LCD for specific clinical indications that constitute covered testing.
Repeat germline testing is covered when it meets the clinical and coverage criteria specified in the MolDX Local Coverage Determination L38351.
To report a Molecular Diagnostic Test (MDT) service, submit the appropriate CPT code, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field, and enter 1 unit of service (UOS).
A molecular or genomic test may be covered when it provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests and is reasonable and necessary for management of the Medicare beneficiary.
A molecular panel is coverable when the medical record documents that the entire panel is reasonable and necessary for the beneficiary’s specific medical problem and will be used in patient management.
Individual gene tests billed separately are coverable when the medical record documents that each individual gene test is reasonable and necessary for the beneficiary’s management.

L38429 — MolDX: Repeat Germline Testing

J05

A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)

J05

A57100 — Billing and Coding: MolDX: Repeat Germline Testing

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

A58918

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