P53, Hemorrhagic disease of newborn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical context documentation implied or recommended in studies/guidelines:
- No explicit documentation requirements are specified in this document chunk.
- For use of ProMark (post-biopsy prostate prognostic testing), documentation should include patient biopsy-based risk classification (NCCN very-low or low risk), life expectancy (>10 years), and candidacy for active surveillance or definitive therapy.
- For use of integrated proteomic classifiers for pulmonary nodules (e.g., Nodify XL2), documentation should include nodule size (8–30 mm), clinician-assessed pre-test probability of malignancy (pCA ≤ 50% for intended-use population), and rationale for test-directed management decisions.
Key Coverage Criteria
- uPA and PAI-1 (urokinase plasminogen activator and plasminogen activator inhibitor-1): risk assessment and prediction of therapeutic response in primary breast cancer; high tissue levels associated with aggressive disease and poor prognosis. (ASCO 2016: may be used to guide adjuvant systemic therapy decisions in ER/PgR-positive, HER2-negative, node-negative breast cancer.)
- IgVH mutation status: prognostic marker in CLL (mutational status divides CLL into prognostic groups; mutation associated with longer survival).
- 1p19q codeletion molecular cytogenetic analysis for astrocytomas and gliomas
- 5-hydroxyindoleacetic acid (5-HIAA) for neuroendocrine tumors
- Afirma Thyroid FNA analysis for assessing fine needle aspiration samples from thyroid nodules that are indeterminate (experimental for other indications; repeat testing is considered experimental and investigational)
- E04.9 Other nontoxic goiter (thyroid nodules/indeterminate thyroid nodules)
1 Active Policy
AETNA-CPB-0352, Tumor Markers
Related Codes
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