Does C54.0 require prior authorization?

No, C54.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`C54.0` — Malignant neoplasm of isthmus uteri

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The intravitreal injection procedure must be coded using CPT code 67028 and the appropriate RT, LT, or 50 site modifier must be appended to indicate unilateral or bilateral service.
Dose and frequency for bevacizumab and biosimilars must follow the FDA label or recognized compendia for off-label uses; compendia cited include AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex DrugDex, NCCN, FDA, and USP.
When billing for metastatic (secondary) disease, use the code for the primary malignancy if the primary tumor is still present, and use the appropriate personal history 'Z' code if the primary malignancy is no longer present.
For Part A and Part B submissions, follow the respective HCPCS coding guidance provided (codes differ by drug form, biosimilar, and effective dates); bill units consistent with the indicated HCPCS code descriptions.

Key Coverage Criteria

For non-ophthalmologic (systemic) use, bevacizumab must be reported with HCPCS code J9035 (injection, bevacizumab, 10 mg) with units reflecting multiples of 10 mg provided.
For non-ophthalmologic use, bevacizumab-awwb (MVASI) must be reported with HCPCS code Q5107 (10 mg).
For non-ophthalmologic use, bevacizumab-bvzr (ZIRABEV) must be reported with HCPCS code Q5118 (10 mg).
Bevacizumab-maly (ALYMSYS/ALYMSYS1) is reported with HCPCS code C9142 for 10/01/2022–12/31/2022 and with HCPCS code Q5126 effective 01/01/2023 (10 mg).
Bevacizumab-adcd (Vegzelma) should be reported with HCPCS code Q5129 effective 04/01/2023.
For the period 09/27/2022 through 03/31/2023 bevacizumab-maly could be reported with miscellaneous code J3590 (per guidance for that timeframe).

20 Active Policies

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

J05

A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

L39040 — MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J05

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When reporting the JW modifier for discarded drug, the medical record must clearly show the amount administered and the amount wasted.

Medical record must document prior anthracycline therapy for patients receiving albumin-bound paclitaxel, or clearly document a clinical contraindication to anthracycline therapy.

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

A60309 — Billing and Coding: MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer

J05

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

J05

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

J05

A58468 — Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers

J05

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

J05

A59915 — Billing and Coding: Pharmacogenomic Testing

J06

L35076 — Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

J06

A52450 — Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

J06

A59901 — Billing and Coding: Bevacizumab and biosimilars

J06

A52370 — Billing and Coding: Bevacizumab and biosimilars

J06

L39995 — Pharmacogenomic Testing

J06

A56827 — Billing and Coding: Proton Beam Therapy

J06

A56874 — Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

J06

A56867 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms

J06

A57452 — Billing and Coding: Peripheral Nerve Blocks

J06

C54.0 — Malignant neoplasm of isthmus uteri