C50.929 — Malignant neoplasm of unspecified site of unspecified 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.
- 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).
- Oncotype DX Breast is intended for patients with estrogen-receptor (ER) positive micrometastases of carcinoma of the breast.
- Oncotype DX Breast is intended for patients with estrogen-receptor (ER) positive breast carcinoma with 1–3 positive lymph nodes.
- Oncotype DX Breast is intended for patients with estrogen-receptor (ER) positive, node-negative invasive carcinoma of the breast.
- When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
20 Active Policies
A55147 — Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update
J05
L38835 — MolDX: Minimal Residual Disease Testing for Cancer
J05
L38158 — MolDX: Next-Generation Sequencing for Solid Tumors
J05
A60309 — Billing and Coding: MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J05
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