D40.0 — Neoplasm of uncertain behavior of prostate
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The supplier must enter a diagnosis code corresponding to the beneficiary's cancer diagnosis on each claim for oral antiemetic drugs.
- A written, signed, and dated order must be received by the supplier before a claim is submitted for any oral antiemetic drug.
- Claims for oral aprepitant (J8501), rolapitant (J8670) or netupitant/palonosetron (J8655) must also be accompanied by a diagnosis code indicating an encounter for antineoplastic chemotherapy.
- Claims billed for code Q0181 must include drug name, manufacturer, dosage strength dispensed, each tablet/suppository/etc, and frequency of administration during the covered time period entered in the narrative field of an electronic claim.
Key Coverage Criteria
- 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.
- An oral antiemetic drug is covered when it is initiated within two hours of administration of the chemotherapeutic agent and continued no more than 48 hours from that time.
- A 3‑drug regimen (NK‑1 antagonist + 5HT3 antagonist + dexamethasone) is covered when all four coverage criteria are met and all three drugs are given in combination.
- Netupitant/palonosetron (fixed combination) is covered when given in conjunction with dexamethasone without requiring a separate 5HT3 antagonist, provided the general coverage criteria are met.
20 Active Policies
L39042 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
J05
A58759 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer
J05
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33578 — Transrectal Ultrasound
J06
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.