Does C25.4 require prior authorization?

No, C25.4 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C25.4` — Malignant neoplasm of endocrine pancreas

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Submit the appropriate CPT code and one (1) unit of service for the test.
Include the assigned DEX Z‑Code™ identifier adjacent to the CPT code in the claim narrative/field (Part B: Loop 2400 or SV101-7 for 837P 5010A1; Part A: SV202-7 for 837I or Block 80 for UB04) or submit the Z‑Code on an attachment for paper claims.
Include at least one appropriate ICD‑10‑CM diagnosis code on the claim.
Medical records must support that the patient meets the clinical indication for immediate PARP inhibitor use, absence of prior relevant germline/somatic testing, and that comprehensive panel testing is not required per LCD L39040.

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.
When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.

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

J05

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

J05

L34658 — Vitamin D Assay Testing

J05

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

J05

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