C61, Malignant neoplasm of prostate
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).
- Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part A claims (Line SV202-7 for 837I electronic claims; Block 80 for UB04 paper claims).
- Select and report an appropriate ICD-10-CM diagnosis code on the claim that supports the medical necessity for the test.
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.
- 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.
- Limited germline testing of a select group of genes (rather than a comprehensive panel) is covered when the patient does not meet criteria for larger panel testing per LCD L39040 and limited testing is necessary to comply with FDA indicated drug usage.
- Coverage applies only if the patient has had no prior germline hereditary cancer testing and no prior somatic testing of the same cancer that already included the genes required to assess PARP inhibitor eligibility.
- Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
20 Active Policies
CGS-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J15
CGS-L38303, MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
J15
CGS-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
J15
CGS-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J15
CGS-L34056, Urodynamics
J15
CGS-L34356, Erythropoiesis Stimulating Agents (ESA)
J15
CGS-L38584, MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
J15
CGS-L38822, MolDX: Minimal Residual Disease Testing for Cancer
J15
CGS-L38067, MolDX: Next-Generation Sequencing for Solid Tumors
J15
CGS-L39648, MolDX: Gene Expression Profile Tests for Decision-Making in Castration Resistant and Metastatic Prostate Cancers
J15
CGS-L36658, Proton Beam Therapy
J15
CGS-L34037, Flow Cytometry
J15
CGS-L36021, MolDX: Molecular Diagnostic Tests (MDT)
J15
A55147, Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update
J5
A55224, Billing and Coding: MolDX: Germline testing for use of PARP inhibitors
J5
A57106, Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease
J5
A57587, Billing and Coding: ProMark Risk Score
J5
A57858, Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors
J5
A56907, Billing and Coding: Bisphosphonate Drug Therapy
J5
A57936, Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J5
Related Codes
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