Does C4A.52 require prior authorization?

No, C4A.52 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C4A.52` — Merkel cell carcinoma of skin of breast

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

A written, signed, and dated order for the oral anticancer drug must be received by the supplier before submitting the claim.
The ICD-10 diagnosis code describing the condition for which the drug is used must be included on each claim.
Claims for J8498 or J8597 must identify the drug name, manufacturer, and dosage strength of each tablet/suppository and must indicate which oral anticancer drug is being used and the prescribed frequency in the narrative field of an electronic claim.
Suppliers must use the NDC that matches the product dispensed and follow NCPDP/NDC billing instructions when submitting claims in NCPDP format.

An oral anticancer drug is covered only if it is an FDA-approved drug or biological and meets all other Medicare statutory/regulatory requirements.
The oral drug must have the same active ingredient and the same chemical/generic name as a non-self-administrable anticancer drug or be a prodrug metabolized to the same active ingredient as the covered non-self-administerable form.
The oral anticancer drug must be used for the same anticancer chemotherapeutic indications (including off-label uses) as the non-self-administerable form.
The oral anticancer drug must be prescribed by a practitioner licensed under state law to prescribe anticancer chemotherapeutic agents and a written, signed, and dated order must be received by the supplier before claim submission.
A self-administered antiemetic billed with HCPCS J8498 or J8597 is covered when it is used with a covered oral anticancer drug, is likely needed to prevent emesis from that anticancer drug, and is administered within 2 hours before the oral anticancer drug.
An oral antiemetic drug is covered when it has been ordered by the treating practitioner as part of a cancer chemotherapy regimen.

L40277 — MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J05

A57936 — Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J05

A57858 — Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

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