Does C18.9 require prior authorization?

No, C18.9 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`C18.9` — Malignant neoplasm of colon, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

Use CPT code 81540 on the claim when billing for Cancer TYPE ID.
Enter '1' in the Days/Unit field on the claim for this test.
Submit the required test identifier information using SV101-7 or SV202-7 (SV202-7 preferred) or via the NTE field if needed.
Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part B claims (Loop 2400 or SV101-7 for 5010A1 837P; Box 19 for paper claims).

Key Coverage Criteria

Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
BRAF V600 mutation testing (cobas® 4800 BRAF V600) is covered to detect BRAF mutation in melanoma to determine eligibility for vemurafenib (Zelboraf) in patients with melanoma that is unresectable or metastatic.
BRAF V600E and V600K mutation testing (ThxID™ BRAF V600/K) is covered to identify melanoma patients whose tumors carry V600E and/or V600K mutations for selection of dabrafenib (Tafinlar) and/or trametinib (Mekinist).
Oncotype DX Colon Cancer Assay is intended to predict recurrence risk for patients with Stage II colon cancer.
Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.

20 Active Policies

L39040 — MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

A55231 — Billing and Coding: MolDX: Oncotype DX Colon Cancer Assay Update

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

Have a follow-up question?

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

Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part A claims (Line SV202-7 for 837I electronic claims; Block 80 for UB04 paper claims).

Select and report an appropriate ICD-10-CM diagnosis code on the claim that supports the medical necessity for the test.

— Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

L36797 — MolDX: NRAS Genetic Testing

J05

L40277 — MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J05

A57581 — Billing and Coding: MolDX: NRAS Genetic Testing

J05

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

J05

A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

A60309 — Billing and Coding: MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J05

A55147 — Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update

J05

A55161 — Billing and Coding: MolDX: FDA-Approved BRAF Tests

J05

A59901 — Billing and Coding: Bevacizumab and biosimilars

J06

A56867 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

J06

A59914 — Billing and Coding: Pharmacogenomic Testing

J06

A59926 — Billing and Coding: Molecular Pathology Procedures

J06

C18.9 — Malignant neoplasm of colon, unspecified