Does C56.1 require prior authorization?

No, C56.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`C56.1` — Malignant neoplasm of right ovary

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medical records for patients receiving a once‑yearly implant must document ongoing follow‑up visits at least every 3 to 4 months and must be provided upon request; lack of requested documentation will result in denial as not medically necessary.
Physician documentation supporting reasonable expectation of survival >12 months is required for coverage of once‑yearly implants for prostate cancer.
Billing frequency should match the drug formulation administered (e.g., bill Vantas 50 mg implant once per 12 months, Eligard 22.5 mg billed per its 3‑month formulation); medical record must support billed frequency when requested.
Use CPT code 81540 on the claim when billing for Cancer TYPE ID.

GnRH/LHRH analogs (leuprolide, goserelin, triptorelin, histrelin, leuprolide mesylate/Camcevi) are covered for FDA‑approved indications and for recognized off‑label uses that meet the criteria of LCD L33394.
Leuprolide acetate and histrelin implants administered every 12 months are covered for treatment of prostate cancer when the treating physician reasonably expects the patient to survive at least 12 months.
GnRH analogs are covered when administered at frequencies consistent with the specific product's labeled duration of action (e.g., monthly, every 3, 4, 6, or 12 months).
Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
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.

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

J05

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

J05

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

J05

L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

J05

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