D45, Polycythemia vera
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 of the condition for which the test is ordered and include an ordering physician/NPP requisition containing the relevant ICD-10-CM diagnosis code.
- Ordering physician/NPP documentation should include history and physical or exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging) that support medical necessity.
- Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.
- For laboratory-developed tests (LDTs)/protocols, documentation must include the diagnostic test/assay, lab/manufacturer, comparable assays (if relevant), assay description, analytical validity, clinical validity, and clinical utility.
Key Coverage Criteria
- When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
- When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
- When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.
- Use modifier 91 only when a test is performed more than once on the same day for the same patient and the repeat testing is necessary to obtain multiple results in the course of treatment.
- Targeted genomic sequence analysis panels for hematolymphoid neoplasms (including acute myelogenous leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms) are covered when the panel contains at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A) and are consistent with NCCN recommendations.
- Targeted genomic sequence analysis panels with 5–50 genes (CPT 81450 or 81451) or 51 or more genes (CPT 81455 or 81456) are represented by these CPT codes and may be used when the panel meets the minimum 5-gene and evidence requirements above.
20 Active Policies
CGS-L38822, MolDX: Minimal Residual Disease Testing for Cancer
J15
CGS-L38070, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies
J15
CGS-L40000, MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms
J15
CGS-L34037, Flow Cytometry
J15
Related Codes
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