D03.121 — Melanoma in situ of left upper eyelid, including canthus
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- For claims with no discarded amounts from single-dose containers or single-use packages, include the JZ modifier as evidence on the claim (effective July 1, 2023).
- Document dose and frequency as consistent with the FDA label or recognized compendia for the indication (including citations to the compendia if used for off-label indications).
Key Coverage Criteria
- Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
- Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.
- Albumin-bound paclitaxel (Abraxane) is covered when prior therapy included an anthracycline unless anthracycline therapy is clinically contraindicated.
- Oncomine DX Test (CPT 0022U) is covered when billed with CPT 0022U and the claim narrative contains the identifier 'Oncomine DX'.
- Rosetta Cancer Origin Test (CPT 81479) is covered when conventional surgical pathology and/or imaging work-up is unable to identify a primary neoplastic site and an 'Initial Work-Up …' comment is submitted on the claim.
- VeriStrat assay (CPT 81538) is covered when a preliminary predictive testing evaluation has been performed prior to ordering and an 'Initial Work-Up …' comment is submitted on the claim.
20 Active Policies
A57477 — Billing and Coding: Mohs Micrographic Surgery
J05
A55161 — Billing and Coding: MolDX: FDA-Approved BRAF Tests
J05
L35494 — Mohs Micrographic Surgery
J05
A56908 — Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift
J05
L36807
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