N42.9 — Disorder of prostate, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Each claim must include the assigned MolDX unique test identifier as additional claim documentation to allow adjudication and crosswalk to the test details on file.
- Laboratories must submit a comprehensive dossier/technical assessment for each new test/assay to MolDX prior to claim submission.
- Providers should use MolDX/Palmetto GBA resources for specific coding, billing information, and coverage determinations (see PalmettoGBA.com/MolDX).
- The assigned unique identifier will serve as a crosswalk to the detailed test information on file, minimizing the need to submit the full TA information with each claim.
Key Coverage Criteria
- MolDX will cover a molecular diagnostic test only if the test has completed MolDX registration and a technical assessment (TA) and demonstrates analytical validity, clinical validity, and clinical utility meeting Medicare's reasonable and necessary standard.
- Tests that have completed registration/TA and have an assigned unique test identifier are eligible for reimbursement for dates of service consistent with the effective date of the MolDX coverage determination.
- This policy applies to all non‑FDA approved laboratory developed tests (LDTs), modified FDA‑approved/cleared kits/tests/assays, tests billed with more than one code (method/serology/anatomic pathology combinations), and tests meeting those descriptions billed with an NOC code; such tests must follow the MolDX registration/TA process to be covered.
- MolDX (Palmetto GBA) coverage determinations are accepted by CGS Administrators and constitute the basis for coverage decisions under this policy.
- Laboratories must follow the test indications as published by the test developer when performing and billing molecular diagnostic tests covered under MolDX.
- Outpatient urine culture testing for bacteria is consideredmedically necessaryto evaluate any of the following situations:
4 Active Policies
ANTHEM-CG-LAB-24 — CG-LAB-24 Outpatient Urine Culture
ANTHEM-CG-LAB-28 — CG-LAB-28 Prostate Specific Antigen Testing
ANTHEM-CG-RAD-28 — CG-RAD-28 Transrectal Ultrasonography
L36021 — MolDX: Molecular Diagnostic Tests (MDT)
Related Codes
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