Does 0242U require prior authorization?

No, 0242U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0242U` — Gene analysis of 55-74 genes associated with solid organ cancer in cell-free circulating dna, targeted genomic sequence analysis panel

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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

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.
Advanced diagnostic laboratory tests (ADLTs) are allowable only when they provide new clinical diagnostic information that cannot be obtained from any other test or combination of tests (per 42 CFR 414.502).

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

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

L39367 — Genetic Testing in Oncology: Specific Tests

J09

A58918 — Billing and Coding: Molecular Pathology and Genetic Testing

J09

L34519

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