Does 0475U require prior authorization?

No, 0475U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0475U`

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.
Claims for repeat germline testing must reference and be supported by documentation consistent with MolDX LCD L38351, including prior germline test reports and clinical rationale for repeat testing.
Follow applicable billing/coding instructions and any required forms or prior authorization processes specified by the LCD or local Medicare Administrative Contractor.
This article provides billing, coding, and related guidelines that complement the Local Coverage Determination (LCD) MolDX: Repeat Germline Testing L38353 and does not by itself define clinical coverage criteria.

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.
Repeat germline testing is covered when it meets the clinical and coverage criteria specified in the MolDX Local Coverage Determination L38351.
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.

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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A57100 — Billing and Coding: MolDX: Repeat Germline Testing

J05

L38429 — MolDX: Repeat Germline Testing

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

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A57331

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