Does 0016M require prior authorization?

No, 0016M does not require prior authorization (high confidence). Code is covered without prior authorization.

`0016M` — Molecular pathology test for genetic analysis of bladder tumor (decipher bladder turbt)

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Report the appropriate CPT code for the Molecular Diagnostic Test service on the claim.
Enter 1 unit of service (UOS) for the Molecular Diagnostic Test service on the claim.
For Part B claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Loop 2400 or SV101-7 for 837P electronic claims and Item 19 for paper claims.
For Part A claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Line SV202-7 for 837I electronic claims and Block 80 for the UB04 claim form.

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).
Billing guidance applies to MolDX prognostic and predictive molecular classifier testing for bladder cancer as referenced by LCD L38684.
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.
When using next generation sequencing (NGS), genes assayed in parallel for the same indication on the same date of service are considered a single panel and may be billed as such when reasonable and necessary.

A58211 — Billing and Coding: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

L38684 — MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer

J05

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

J05

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