Does 81438 require prior authorization?

No, 81438 does not require prior authorization (high confidence). Code is covered without prior authorization.

`81438`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Claims must document adherence to LCD L39365 and to AMA CPT Codebook and Medicare NCCI Policy Manual rules and guidelines; providers billing Medicare are expected to follow all instructions in these sources.
Document the treating physician's order and that the physician ordered the test and will use the results in management of the beneficiary's specific medical problem.
Include documentation of specimen source(s), number of specimens, number and type of probes/procedures performed, testing methodology/technology used, and the specific genes analyzed (or gene list for the panel).
When billing a panel code with mandatory genes (e.g., CPT 81436), retain documentation proving the panel included the required genes named in the CPT descriptor (e.g., MLH1, MSH2, EPCAM, SMAD4, STK11).

Genetic testing CPT codes are covered when testing is reasonable and necessary per Local Coverage Determination L39365 and the AMA CPT Codebook and Medicare NCCI Policy Manual instructions are followed.
If a CPT code specifies a medical condition (e.g., CPT 81432 - hereditary breast cancer-related disorders), bill that code only when the beneficiary's documented disease matches the code's described medical condition and all genes billed under that code relate to that condition.
When a CPT genomic sequencing panel (GSP) code defines required genes (e.g., CPT 81436), bill the panel code only if the test includes all mandatory genes listed in the code description; bill the panel as a single unit of service regardless of the number of genes tested.
When a CPT code specifies a particular technology or methodology (e.g., RT-PCR, microarray, NGS in CPT 81518/81521/81523), bill that code only if the specified technology/methodology was used.
For FISH and probe-based CPT codes, bill units of service based on the applicable UOS definition in the CPT Codebook/NCCI (e.g., multiple slides/blocks from the same specimen source are counted as one source-specimen UOS).
When 5–50 genes are ordered as a molecular testing panel, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) rather than individual single-gene CPT codes.

A59926 — Billing and Coding: Molecular Pathology Procedures

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A59492 — Billing and Coding: Genetic Testing for Oncology

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A59491 — Billing and Coding: Genetic Testing for Oncology

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UMR-POL-UMR-genetic-testing-hereditary-cancer — Genetic Testing for Hereditary Cancer

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