Does 0216U require prior authorization?

No, 0216U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0216U`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The article does not specify documentation requirements; follow the documentation, medical record, and prior authorization requirements described in LCD MolDX: Repeat Germline Testing L38429 and MolDX program guidance.
For Part A UB04 paper claim forms, enter the DEX Z-Code adjacent to the CPT code in Block 80.
For Part B electronic 5010A1 837P claims, enter the DEX Z-Code adjacent to the CPT code in Loop 2400 or SV101-7.
For Part B paper claims, enter the DEX Z-Code adjacent to the CPT code in Box 19 of the paper claim form.

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.
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.
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.

L38429 — MolDX: Repeat Germline Testing

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

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

J05

A57100 — Billing and Coding: MolDX: Repeat Germline Testing

J05

A58918

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