C47.21 — Malignant neoplasm of peripheral nerves of right lower limb, including hip
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.
- Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
- 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.
20 Active Policies
A57936 — Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J05
L38158 — MolDX: Next-Generation Sequencing for Solid Tumors
J05
A57858 — Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors
J05
A57477 — Billing and Coding: Mohs Micrographic Surgery
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.