Does C43.4 require prior authorization?

No, C43.4 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C43.4` — Malignant melanoma of scalp and neck

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.
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).

L38018 — MolDX: Melanoma Risk Stratification Molecular Testing

J05

A56636 — Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

L38835

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