Z92.3 — Personal history of irradiation
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity for services included in the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Include a treatment prescription that defines treatment goals and specific dose-volume parameters for the target and nearby critical structures, and details of beam delivery such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
- Include a physician-signed treatment plan that meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) accounting for expected uncertainties.
- Describe the target setup verification methodology, including patient positioning, immobilization, and use of image guidance.
Key Coverage Criteria
- Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.
- Stereotactic radiosurgery (SRS) is typically furnished as a single session; when more than one session is required, bill using stereotactic body radiation therapy (SBRT) codes instead of SRS codes.
- Coverage on an individual (redetermination/appeal) basis may be considered for lesions that require a high radiation dose per fraction to avoid exposure of surrounding tissues when documentation and supporting literature are provided.
- Ultrasound of soft tissues of the head and neck is covered when it is reasonable and necessary as defined by Local Coverage Determination L34027.
- Pharmacogenomics (PGx) testing is covered when it is reasonable and necessary per LCD L39063 and Medicare coverage rules for the beneficiary's clinical indication.
- CPT 81418 (PGx multi-gene panel) is covered when the test assays at least 6 genes, including CYP2C19 and CYP2D6 and CYP2D6 duplication/deletion analysis, and the panel is clinically indicated to guide drug therapy.
20 Active Policies
A56827 — Billing and Coding: Proton Beam Therapy
J06
L35076 — Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
J06
L35075 — Proton Beam Therapy
J06
A59914 — Billing and Coding: Pharmacogenomic Testing
J06
L39995
Related Codes
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