Does C52 require prior authorization?

No, C52 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C52` — Malignant neoplasm of vagina

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports medical necessity for services included in the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Include a treatment prescription that defines treatment goals and specific dose-volume parameters for the target and nearby critical structures, and details of beam delivery such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
Include a physician-signed treatment plan that meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) accounting for expected uncertainties.
Describe the target setup verification methodology, including patient positioning, immobilization, and use of image guidance.

Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.
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.
Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).
Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
Report histopathologic examination separately when performed using CPT codes 88304-88305.
Select the CPT code for lesion removal by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision, with measurement made prior to excision.

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

J05

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

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

L38168 — MolDX: Plasma-Based Genomic Profiling in Solid Tumors

J05

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