Does 0474U require prior authorization?

No, 0474U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0474U`

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).
Molecular diagnostic tests (MDTs) that have completed MolDx registration and technical assessment (TA) and are listed as covered by MolDx are covered when they meet Medicare's reasonable and necessary criteria.
Tests that demonstrate analytical validity, clinical validity, and clinical utility sufficient to meet Medicare's reasonable and necessary requirement are covered.
Tests performed for a diagnosis-specific indication or to provide results that will improve patient outcomes or change clinician management are covered when other MolDx requirements are met.
The policy applies to non‑FDA laboratory developed tests (LDTs), modified FDA‑approved/cleared kits, and tests/assays billed with more than one HIPAA‑compliant code (including NOC) that meet MolDx registration/TA and validity/utility requirements.

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

L38429 — MolDX: Repeat Germline Testing

J05

CGS-L36021

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