Does C17.3 require prior authorization?

No, C17.3 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`C17.3`, Meckel's diverticulum, malignant

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

For esophageal capsule, document cirrhosis/portal hypertension status and that the patient is anticipated to tolerate adequate doses of beta-blockers (or else conventional endoscopy is required).
Document prior negative or non-diagnostic evaluations (upper GI endoscopy and colonoscopy; push enteroscopy, nuclear imaging, or radiology) before covering small-bowel capsule endoscopy for obscure bleeding or other small-bowel indications.
For suspected Crohn's disease, document strong clinical suspicion, negative colonoscopy, and physician judgment that there is no intestinal stricture prior to capsule endoscopy.
When capsule endoscopy is used for small-bowel neoplasm detection, document symptomatic presentation (e.g., bleeding) or documented polyposis syndrome, and prior diagnostic testing performed; if intussusception is documented, note that prior endoscopy requirements may be waived.

Key Coverage Criteria

Esophageal capsule endoscopy is covered to evaluate for medium-to-large esophageal varices in patients with cirrhosis and portal hypertension who have no prior variceal bleeding and are anticipated to tolerate adequate doses of beta-blockers.
Small-bowel capsule endoscopy is covered for evaluation of occult gastrointestinal bleeding when the source was not identified by prior upper GI endoscopy and colonoscopy (push enteroscopy, nuclear imaging, or radiology also negative or non-diagnostic).
Capsule endoscopy is covered for detection of small-bowel neoplasms when no prior study has confirmed the diagnosis and the patient is symptomatic (e.g., GI bleeding) or has a documented polyposis syndrome associated with small-bowel neoplasia; prior upper/lower endoscopy and other diagnostic testing must have been performed.
For patients with documented small-bowel intussusception without established etiology, capsule endoscopy is covered for neoplasm detection and the requirement for prior upper and lower endoscopies may be waived.
Capsule endoscopy is covered to establish a diagnosis of Crohn's disease when the diagnosis is not previously confirmed, there is strong clinical suspicion (abdominal pain, weight loss, diarrhea, anorexia, bleeding, inflammatory markers), there is no clinical concern for intestinal stricture, and colonoscopy is negative.
Capsule endoscopy is reasonable for evaluation of malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy when suspected to originate in the small intestinal mucosa after prior negative or non-diagnostic flexible endoscopy, radiologic, and microbiologic evaluations.

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C17.3, Meckel's diverticulum, malignant