Does 88363 require prior authorization?

No, 88363 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 88363?

Medicare facility rate: $15.36. Non-facility rate: $22.71. Work RVU: 0.36.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.36

Facility

$15.36

Non-Facility

$22.71

Precertification documentation: use Aetna precertification process (phone (866) 752-7021 or fax (888) 267-3277) and submit Statement of Medical Necessity (SMN) precertification forms as required by Aetna.
Molecular testing results: RAS (KRAS and NRAS) mutation status (must be negative/wild-type for Criteria Set 1) — relevant CPT codes listed (e.g., 81275, 81276, 81311, 81210, 81404) to support testing.
If BRAF V600E positive: documentation of BRAF V600E test result and treatment plan showing panitumumab will be used in combination with encorafenib (Braftovi).
If KRAS G12C positive: documentation of KRAS G12C test result and treatment plan showing panitumumab will be used in combination with sotorasib (Lumakras) or adagrasib (Krazati), and documentation that the member previously received chemotherapy.

Continuation of Therapy: "Aetna considers continuation of panitumumab (Vectibix) therapy medically necessary in members requesting reauthorization for an indication listed in Section I when there is no evidence of unacceptable toxicity or disease progression while on the current regimen."
FDA-Approved Indications (background information included in policy): "Vectibix is indicated for the treatment of patients with wild-type RAS (defined as wild-type in both KRAS and NRAS as determined by an FDA-approved test for this use) metastatic colorectal cancer (mCRC): As first-line therapy in combination with FOLFOX; As monotherapy following disease progression after prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy."
C18.0 - C18.9 Malignant neoplasm of colon [covered for left-sided tumors only]
C19 - C21.8 Malignant neoplasm of rectosigmoid junction, rectum, anus and anal canal
CPT 81275 KRAS gene analysis; variants in exon 2 (eg, codons 12 and 13) — covered if selection criteria are met
CPT 81276 additional variant(s) (eg, codon 61, codon 146) — covered if selection criteria are met

AETNA-CPB-0352 — Tumor Markers

AETNA-CPB-0748 — Panitumumab (Vectibix)

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