Does 0543U require prior authorization?

No, 0543U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0543U`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
For Part A electronic 837I claims, enter the DEX Z-Code adjacent to the CPT code on line SV202-7.

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).
For Next-Generation Sequencing (NGS) services for solid tumors covered under MolDX LCD L38045, submit the claim using the appropriate CPT code for the NGS service.
Include an appropriate ICD-10-CM diagnosis code that supports medical necessity for the NGS for solid tumors service.
Next-Generation Sequencing (NGS) for solid tumors billed under MolDX must be reported using the billing/coding elements specified in this article and in the referenced LCD L38067.
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.

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

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

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L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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A57858 — Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors

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