Does A04.1 require prior authorization?

No, A04.1 does not require prior authorization (high confidence). Covered without prior authorization.

`A04.1`, Enterotoxigenic Escherichia coli infection

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Submit the appropriate CPT® or PLA code (or CPT® 87999 if no specific code) with each claim and ensure the CPT/HCPCS code describes the service performed.
Include ICD-10-CM diagnosis code(s) that support medical necessity on every claim and retain medical record documentation that supports the selected diagnosis codes.
When applicable, enter the DEX Z-Code identifier adjacent to the CPT® code in the specified claim fields for Part A (SV202-7 or UB04 Block 80) and Part B (Loop 2400/SV101-7 or paper Box 19); do not add extra characters in SV101-7.
Tests using CPT® code 87999 or tests without an existing CPT® code require submission of a Z-Code and completion of a MolDX Technical Assessment (TA) to establish coverage.

Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
FDA-approved or cleared molecular infectious disease tests performed consistent with their intended use labeling are covered without a DEX Z-Code and Technical Assessment when billed with appropriate ICD-10-CM diagnosis codes and supporting documentation.
Expanded (>5 pathogens) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered if billed from place of service (POS) 19, 21, 22, or 23, or if ordered by an appropriate specialist depending on beneficiary immune status and the specialist is diagnosing/treating the beneficiary.
For immune-compromised beneficiaries, expanded panels (RP/PNP/GI/other panels) are covered when ordered by a specialist in Infectious Diseases, Oncology, Transplant, Pulmonology (for RP/PNP), or Gastroenterology (for GI) who is diagnosing and treating the beneficiary.
Pre-transplant evaluation testing for an immune-compromised beneficiary is covered regardless of symptoms when clear documentation of the pre-transplant evaluation accompanies the claim.
Additional testing for organisms not included in a panel may be reasonable and covered when ordered in addition to the panel and supported by documentation in the medical record demonstrating non-duplication and medical necessity.

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J18-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J18

WPS-J5-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58761, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

Ask Backwork about documentation requirements, denial risks, or coverage in your state.