Does D37.5 require prior authorization?

No, D37.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D37.5` — Neoplasm of uncertain behavior of rectum

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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).

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.
An oral anticancer drug is covered only if it is an FDA-approved drug or biological and meets all other Medicare statutory/regulatory requirements.
The oral drug must have the same active ingredient and the same chemical/generic name as a non-self-administrable anticancer drug or be a prodrug metabolized to the same active ingredient as the covered non-self-administerable form.
The oral anticancer drug must be used for the same anticancer chemotherapeutic indications (including off-label uses) as the non-self-administerable form.

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L33578 — Transrectal Ultrasound

J06

L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

J06

A52450

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