Does 81451 require prior authorization?

No, 81451 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81451?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

For services requiring a referring/ordering physician, the claim must report the referring/ordering physician's name and NPI.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the genomic sequencing service was performed.
Documentation should support that the panel's biomarkers meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and demonstrate associated clinical utility.
Laboratories and clinicians including non‑NCCN genes in panels are advised to adhere to regulatory and institutional oversight mechanisms to document clinical validity and utility.

Targeted genomic sequence analysis panels for hematolymphoid neoplasms (including acute myelogenous leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms) are covered when the panel contains at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and are consistent with NCCN recommendations.
Targeted genomic sequence analysis panels with 5–50 genes (CPT 81450 or 81451) or 51 or more genes (CPT 81455 or 81456) are represented by these CPT codes and may be used when the panel meets the minimum 5-gene and evidence requirements above.
Minimal residual disease (MRD) testing in myelodysplastic syndromes (MDS) for single-gene tests may be covered when the test is medically reasonable and necessary for the individual patient's care.
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).
Bill this policy's procedures when submitting claims for Next-Generation Sequencing (NGS) lab-developed tests (LDTs) for myeloid malignancies or suspected myeloid malignancies.
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.

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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L38176 — MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

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

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A57878 — Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

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