Does C34.11 require prior authorization?

No, C34.11 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`C34.11` — Malignant neoplasm of upper lobe, right bronchus or lung

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.
The cobas EGFR Mutation Test v2 is indicated as a companion diagnostic to detect defined EGFR mutations in patients with non-small cell lung cancer (NSCLC) using DNA from formalin-fixed paraffin-embedded tumor tissue (FFPET) or circulating tumor DNA (cfDNA) from plasma to aid selection of targeted therapies per FDA-approved labeling.
Patients with positive cobas EGFR Mutation Test v2 results for EGFR exon 19 deletions or L858R in plasma are eligible for treatment with erlotinib (TARCEVA) according to the test's FDA-approved indication.
Detection of EGFR T790M by an FDA-approved EGFR kit (e.g., cobas) in NSCLC patients is indicated to identify patients eligible for osimertinib (TAGRISSO) per FDA-approved labeling.
The therascreen EGFR RGQ PCR kit is indicated for detection of EGFR mutations in NSCLC tumor tissue (FFPET) to help select patients for afatinib (GILOTRIF) according to FDA-approved labeling.
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.

20 Active Policies

A56333 — Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

J05

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

J05

L37921 — MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

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.

L38443 — MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

J05

L38168 — MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

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

J05

A57112 — Billing and Coding: MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer

J05

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

J05

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

J05

A57936 — Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J05

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

J05

A55193 — Billing and Coding: MolDX: FDA-Approved EGFR Tests

J05

A57452 — Billing and Coding: Peripheral Nerve Blocks

J06

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

J06

A56874 — Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

J06

A59901 — Billing and Coding: Bevacizumab and biosimilars

J06

A56199 — Billing and Coding: Molecular Pathology Procedures

J06

C34.11 — Malignant neoplasm of upper lobe, right bronchus or lung