Does E31.23 require prior authorization?

No, E31.23 does not require prior authorization (high confidence). Covered without prior authorization.

`E31.23`, Multiple endocrine neoplasia [MEN] type IIB

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.
Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.

CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
CEA testing is consideredmedically necessaryforeitherclinical scenario (AorB)andthe following conditions (C):As part of initial evaluation for suspected or diagnosed disease;orTo determine whether residual tumor exists post-surgical therapy;andConditions:Ampullary adenocarcinoma;orAppendiceal adenocarcinoma;orBiliary tract cancer (gallbladder, cholangiocarcinoma);orColorectal cancer;orMalignant pleural mesothelioma;orMedullary thyroid carcinoma;orMetastatic breast cancer;orMultiple Endocrine Neo [...]
As part of initial evaluation for suspected or diagnosed disease;or
To determine whether residual tumor exists post-surgical therapy;and
Conditions:Ampullary adenocarcinoma;orAppendiceal adenocarcinoma;orBiliary tract cancer (gallbladder, cholangiocarcinoma);orColorectal cancer;orMalignant pleural mesothelioma;orMedullary thyroid carcinoma;orMetastatic breast cancer;orMultiple Endocrine Neoplasia Type 2 (MEN2);orOvarian, primary peritoneal, or fallopian tube cancer;orPancreatic neoplasms;orRectal cancer;orSmall bowel adenocarcinoma (duodenum, jejunum, ileum).

ANTHEM-CG-LAB-33, Carcinoembryonic Antigen Testing

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

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