Does 0403U require prior authorization?

No, 0403U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0403U`

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).
Molecular biomarker testing to risk-stratify patients at increased risk for prostate cancer when allowed by MolDX Local Coverage Determination L39042.
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.

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

J05

A58759 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

L39042 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J05

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