C44.42 — Squamous cell carcinoma of skin of scalp and neck
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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.
- Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
- 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.
20 Active Policies
L40277 — 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
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
L40192 — Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)
J05
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