Z80.8 — Family history of malignant neoplasm of other organs or systems
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of genetic counseling (recommendation/notes) prior to testing and evidence that testing is being used to guide clinical management (e.g., consideration of prophylactic thyroidectomy, surveillance plans for mutation-positive individuals).
- Appropriate ICD-10 diagnosis codes on claims supporting medical necessity per the CPB (for covered indications: e.g., C73–C75.9, E07.0, Q43.1, Z80.8).
- The policy text does not specify explicit required documentation fields or paperwork (no dedicated 'Documentation Requirements' section).
- Implied/necessary documentation to support medical necessity (as extractable from the policy): documentation of family history (first- or second-degree relatives as applicable), diagnosis of MTC or apparently sporadic MTC, presence of Hirschsprung disease, presence of C-cell hyperplasia, presence of two or more endocrine tumors, or diagnosis of pheochromocytoma/paraganglioma/parathyroid carcinoma.
Key Coverage Criteria
- ICD-10 diagnosis listed as covered if selection criteria are met: E07.0 (Hypersecretion of calcitonin).
- ICD-10 diagnosis listed as covered if selection criteria are met: Q43.1 (Hirschsprung's disease).
- Tests for germline point mutations in the RET gene medically necessary for members who meet any of the following high-risk criteria:
- Members who have first-degree blood relatives (ie, parent, full-sibling, child) with medullary thyroid carcinoma (MTC).
- Members who have first- (i.e., parent, full-sibling, child) or second-degree (i.e., aunt, uncle, grandparent, grandchild, niece, nephew, half-sibling) blood relatives and germline RET mutations (Testing strategy: Test for specific familial mutation).
- Members with any of the following: C-cell hyperplasia.
2 Active Policies
CIGNA-0549 — Head and Neck Ultrasound - (0549)
AETNA-CPB-0319 — RET Proto-Oncogene Testing
Related Codes
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