Does C25.0 require prior authorization?

No, C25.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C25.0` — Malignant neoplasm of head of pancreas

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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).

Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
Germline testing is covered when the patient has ovarian, breast, pancreatic, or prostate cancer and meets clinical indication for immediate treatment with an FDA‑approved PARP inhibitor.
Testing for deleterious variants in homologous recombination repair (HRR) genes (e.g., BRCA1, BRCA2) is covered as an aid when results will be used to determine eligibility for PARP inhibitor therapy.
Limited germline testing of a select group of genes (rather than a comprehensive panel) is covered when the patient does not meet criteria for larger panel testing per LCD L39040 and limited testing is necessary to comply with FDA indicated drug usage.
Coverage applies only if the patient has had no prior germline hereditary cancer testing and no prior somatic testing of the same cancer that already included the genes required to assess PARP inhibitor eligibility.
Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.

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

J05

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

J05

L38158 — 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

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