C43.31 — Malignant melanoma of nose
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Report BRAF V600 test kit services using CPT code 81210 on claims.
- Submit the assigned DEX Z-Code™ Identifier in the comment/narrative field: Loop 2400 or SV101-7 for 5010A1 837P electronic claims; alternatively use SV202-7 (preferred) or the NTE field.
- For paper Part B claims attach the DEX Z-Code identifier to the claim; for Part A enter the DEX Z-Code adjacent to CPT on Line SV202-7 for 837I electronic claims or Block 80 on the UB-04 form.
- Select and report the appropriate ICD-10-CM diagnosis code for melanoma on the claim.
Key Coverage Criteria
- BRAF V600 mutation testing (cobas® 4800 BRAF V600) is covered to detect BRAF mutation in melanoma to determine eligibility for vemurafenib (Zelboraf) in patients with melanoma that is unresectable or metastatic.
- BRAF V600E and V600K mutation testing (ThxID™ BRAF V600/K) is covered to identify melanoma patients whose tumors carry V600E and/or V600K mutations for selection of dabrafenib (Tafinlar) and/or trametinib (Mekinist).
- Mohs micrographic surgery is covered when selected because the lesion's complexity (e.g., poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), size, or anatomic location requires maximal tissue conservation and other approaches (standard excision or destruction) are not medically reasonable or necessary.
- Mohs surgery is considered covered when the surgeon performs both the surgical excision and the pathologic examination (surgeon acting in integrated surgical and pathology roles) as part of the Mohs technique.
- Initial MRD testing is covered for patients with cancer when baseline tumor profiling from a prior analysis is utilized, using listed bespoke/plasma-series MRD tests (e.g., Signatera Bespoke Assay Design + Plasma Series Bundle, RaDaR Bespoke Assay Design + Plasma Series Bundle, Oncodetect Bespoke Assay Design + Plasma Test Bundle, Guardant Reveal MRD Bundle, Guardant360 Response).
- Subsequent MRD testing for patients with cancer is covered only if there is clinical evidence of an a priori change in tumor genetic content in accordance with NCD 90.2.
20 Active Policies
L38018 — MolDX: Melanoma Risk Stratification Molecular Testing
J05
A55161 — Billing and Coding: MolDX: FDA-Approved BRAF Tests
J05
L35494 — Mohs Micrographic Surgery
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
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