Does C41.3 require prior authorization?

No, C41.3 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C41.3` — Malignant neoplasm of ribs, sternum and clavicle

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.
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.
Coverage is allowed for targeted genomic sequence analysis panels for treatment of solid organ neoplasms when the panel is a DNA analysis panel containing at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria.
Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).
Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
Stereotactic radiosurgery (SRS) is typically furnished as a single session; when more than one session is required, bill using stereotactic body radiation therapy (SBRT) codes instead of SRS codes.

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

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

J05

L40277 — 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.