C50.421 — Malignant neoplasm of upper-outer quadrant of right male breast
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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).
Key Coverage Criteria
- Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
- MammaPrint® is indicated to analyze gene expression of FFPE breast cancer tissue to assess a patient's risk for distant metastasis (early-stage breast cancer).
- The test may be performed using either the FDA-cleared microarray assay or a next-generation sequencing (NGS)-based assay.
- PIK3CA targeted gene sequencing is indicated to detect PIK3CA mutations in patients with hormone receptor (HR)-positive, HER2-negative, advanced or metastatic breast cancer (postmenopausal women and men) who have progressed on or after an endocrine-based regimen when results will inform treatment with alpelisib (Piqray).
- Germline testing is covered when the patient has ovarian, breast, pancreatic, or prostate cancer and meets clinical indication for immediate treatment with an FDA‑approved PARP inhibitor.
- Testing for deleterious variants in homologous recombination repair (HRR) genes (e.g., BRCA1, BRCA2) is covered as an aid when results will be used to determine eligibility for PARP inhibitor therapy.
20 Active Policies
A60309 — Billing and Coding: MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J05
L39040 — MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
J05
A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
J05
A59561 — Billing and Coding: Bisphosphonate Drug Therapy
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.