C44.1391 — Sebaceous cell carcinoma of skin of left upper eyelid, including canthus
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.
- Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.
- For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
- Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).
Key Coverage Criteria
- Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
- Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
- Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
- Removal of benign or malignant skin lesions is addressed per the Local Coverage Determination L33445 and related billing/coding guidance.
- Diagnosis code L82.0 (inflamed seborrheic keratosis) may be used when the medical record documents the patient's complaint or the physician's physical findings for the lesion.
- Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
20 Active Policies
L35075 — Proton Beam Therapy
J06
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L36850 — Peripheral Nerve Blocks
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
A52450 — Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )
Related Codes
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