Does C25.1 require prior authorization?

No, C25.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C25.1` — Malignant neoplasm of body of pancreas

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.
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.

L34658 — Vitamin D Assay Testing

J05

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

J05

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

J05

L39040 — 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.