Does E70.81 require prior authorization?

No, E70.81 does not require prior authorization (high confidence). Covered without prior authorization.

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`E70.81`, Aromatic L-amino acid decarboxylase deficiency

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must include the referring/ordering physician's name and NPI when required by the service, and all same-day services for the same beneficiary by the same provider must be billed on the same claim.
Medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests, and a signed and dated office visit/operative report.
For fundus photography, retain a copy of the photographs in the record, include an interpretation and report, document whether the pupil was dilated and which drug was used, and maintain legible documentation of medical necessity.
For extended ophthalmoscopy, retain a detailed per-eye retinal drawing (minimum 3–4 inches, labeled; 4–6 colors preferred), document optic nerve drawings for glaucoma with cupping/disc rim/pallor/slope and surrounding pathology, note method of examination and pupil dilation/drug, and document findings and plan.

Key Coverage Criteria

Fundus photography (CPT 92250, 92228) is covered when medical necessity is documented in the patient's medical record including relevant history, physical exam, results of pertinent tests, an interpretation/report, and retained copies of the photographs.
Extended ophthalmoscopy (CPT 92201, 92202) is covered when medical necessity is documented per-eye with a retinal drawing that meets the policy specifications, relevant history, physical exam, and test results recorded.
Professional (26) and/or technical (TC) components of fundus photography CPT 92250 and 92228 may be billed separately when only one component is performed, with the appropriate modifier reported.
When extended ophthalmoscopy is performed during a global surgical period and is unrelated to the surgery (same provider), bill the extended ophthalmoscopy with modifier 79 (and the appropriate site modifier if unilateral).
Kebilidi is proven and medically necessary for the treatment of AADC deficiency in patients who meet all of the following criteria: genetic confirmation of AADC deficiency due to biallelic DDC mutations; clinical characteristics of AADC deficiency; decreased plasma AADC activity; skull maturity for stereotactic neurosurgical administration; persistent symptoms despite standard medical therapy; inability to ambulate independently; anti-AAV2 antibody titer not exceeding 1:1200 by ELISA; neurology/ [...]
Infant (i.e., ≤ 12 months of age) nutritional formula is considered medically necessary when specifically formulated for the treatment of an inborn error of metabolism (e.g., disorder of amino acid or organic acid metabolism).

5 Active Policies

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

CIGNA-0136, Infant Nutritional Formula

UHC-POL-kebilidi, Kebilidi (Eladocagene Exuparvovec-Tneq)

A57071

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E70.81, Aromatic L-amino acid decarboxylase deficiency