Does D07.5 require prior authorization?

No, D07.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D07.5` — Carcinoma in situ of prostate

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.
The supplier must enter a diagnosis code corresponding to the beneficiary's cancer diagnosis on each claim for oral antiemetic drugs.

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).
An oral antiemetic drug is covered when it has been ordered by the treating practitioner as part of a cancer chemotherapy regimen.
An oral antiemetic drug is covered when the drug is FDA‑approved for use as an antiemetic.
An oral antiemetic drug is covered when it is used as a full therapeutic replacement for an intravenous antiemetic that would otherwise have been administered at the time of the chemotherapy treatment.

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

J05

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

J05

A57427 — Billing and Coding: Transrectal Ultrasound

J06

A52453 — Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

J06

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