Does C21.0 require prior authorization?

No, C21.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C21.0` — Malignant neoplasm of anus, unspecified

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.
For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).

Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
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).
Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

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

J05

A58468 — Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

J05

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