C68.1 — Malignant neoplasm of paraurethral glands
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must document that the testing is expected to influence treatment and include the ordering physician/NPP history and physical, exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging).
- The laboratory or billing provider must retain the physician requisition that sets forth the diagnosis/ICD-10-CM code that warrants the test(s).
- Performing laboratory documentation (when requested) must include lab accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records.
- For laboratory-developed tests (LDTs)/protocols (when requested) documentation must include assay description, lab/manufacturer, comparable assays/services (if relevant), and evidence of analytical validity, clinical validity, and clinical utility.
Key Coverage Criteria
- 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.
- Initial MRD testing is covered for patients with cancer when baseline tumor profiling from a prior analysis is utilized, using listed bespoke/plasma-series MRD tests (e.g., Signatera Bespoke Assay Design + Plasma Series Bundle, RaDaR Bespoke Assay Design + Plasma Series Bundle, Oncodetect Bespoke Assay Design + Plasma Test Bundle, Guardant Reveal MRD Bundle, Guardant360 Response).
20 Active Policies
A58468 — Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers
J05
L38158 — MolDX: Next-Generation Sequencing for Solid Tumors
J05
L38168 — MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J05
A60309 — Billing and Coding: MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J05
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