Does D75.89 require prior authorization?

No, D75.89 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`D75.89` — Other specified diseases of blood and blood-forming organs

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.
CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.

20 Active Policies

A59939 — Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J05

A59938 — Billing and Coding: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J05

L40021 — MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J05

A57594 — Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

J05

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When CPT 81479 (unlisted molecular pathology procedure) is used, documentation must clearly identify the unique molecular pathology procedure performed and link that procedure to the billed code.

When multiple procedure codes (unique and/or unlisted) are submitted on a claim, the documentation supporting each code must be easily identifiable and linkable to the billed codes.

L40022 — MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J05

L35751 — Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

J05

A57878 — Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J05

L38176 — MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J05

A56199 — Billing and Coding: Molecular Pathology Procedures

J06

A56793 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

J06

A59898 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

J06

A59926 — Billing and Coding: Molecular Pathology Procedures

J06

L35000 — Molecular Pathology Procedures

J06

L37606 — Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

J06

A59837 — Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

A56464 — Billing and Coding: Flow Cytometry

A59918 — Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

A59919 — Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

L38047 — MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

A59826 — Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

D75.89 — Other specified diseases of blood and blood-forming organs