Does D12.5 require prior authorization?

No, D12.5 does not require prior authorization (high confidence). Covered without prior authorization.

`D12.5`, Benign neoplasm of sigmoid colon

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The submitted CPT/HCPCS code must accurately describe the service performed.
All documentation must be maintained in the patient medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Genetic testing for Lynch syndrome is covered when the patient meets the reasonable and necessary clinical criteria specified in LCD L34912.

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J18-L34081, Endoscopy by Capsule

J18

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

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