C52, Malignant neoplasm of vagina
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
Key Coverage Criteria
- 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.
- CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
- Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
20 Active Policies
CGS-L34037, Flow Cytometry
J15
CGS-L38067, MolDX: Next-Generation Sequencing for Solid Tumors
J15
CGS-L36658, Proton Beam Therapy
J15
CGS-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J15
CGS-L34356, Erythropoiesis Stimulating Agents (ESA)
Related Codes
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