Does A04.4 require prior authorization?

No, A04.4 does not require prior authorization (high confidence). Covered without prior authorization.

`A04.4`, Other intestinal Escherichia coli infections

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

When billing Part B claims, include the drug(s) being considered that require the PGx test on the applicable detail line (eg, 2400 loop on 837P); for Part A include Loop SV202-7 (837I) or Block 80 (UB04); for paper Part B include Box 19.
When billing CPT 81418, list the names of all specific genes tested (in addition to CYP2C19 and CYP2D6) in the claim comment/narrative field appropriate to the claim type (Part A SV202-7/Block80; Part B Loop 2400/SV101-7/Box19).
Document prior germline testing history and the clinical rationale or evidence of established clinical utility for any non-duplicative components to support that the service billed is reasonable and necessary.
For multi-gene testing coding and billing guidance, follow the Molecular Pathology and Genetic Testing Article A58917 as applicable.

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.
A clinician-ordered single gene or allele test is considered covered when the billed component corresponds to the single gene/allele that was reasonable and necessary, even if the laboratory platform concurrently interrogated other genes operationally.
Germline testing panels that include some previously tested genetic content may be covered if there is established clinical utility for the remaining non-duplicative genetic components of the panel.
Genes may be assayed serially or in parallel; additional gene analyses done after a reflex decision are covered when those reflexive analyses are reasonable and necessary for the beneficiary's care.
Germline pharmacogenomic (PGx) testing is covered when the test results have established clinical utility to guide management of a specific drug therapy for the Medicare beneficiary.

A59915, Billing and Coding: Pharmacogenomic Testing

NGS-J6-L39995, Pharmacogenomic Testing

FIRST_COAST-L39073, Pharmacogenomics Testing

A58812, Billing and Coding: Pharmacogenomics Testing

NOVITAS-JH-L39063

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