Does E72.51 require prior authorization?

No, E72.51 does not require prior authorization (high confidence). Covered without prior authorization.

`E72.51`, Non-ketotic hyperglycinemia

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Note in policy: 'MRS is considered medically necessary for disease monitoring of these diagnoses when recent MRI findings are inconclusive and a change in therapy is being considered.'
Implied / inferred requirement: documentation of recent MRI findings that are inconclusive (i.e., copies of MRI reports/images) and documentation that the MRS findings will be used to determine management (e.g., to determine whether biopsy/resection can be safely postponed or to distinguish recurrent tumor from radiation necrosis).
Use of appropriate diagnosis code(s) consistent with the policy's 'ICD-10 codes covered if selection criteria are met'—the claim should reflect a covered indication listed in the policy when selection criteria are met.
Use of the covered CPT code for MRS when performed for a listed medically necessary indication: 76390 (Magnetic resonance spectroscopy).

Diagnosis of the following disorders: Metachromatic leukodystrophy (MCL);
Myocardial disease — (referenced as a clinical application of MRS)
Distinguishing recurrent brain tumor from radiation-induced tumor necrosis;
Diagnosis and monitoring of the following metabolic disorders: Canavan disease;
Diagnosis and monitoring of the following metabolic disorders: Creatine deficiency;
Diagnosis and monitoring of the following metabolic disorders: Nonketotic hyperglycinemia;

CIGNA-0136, Infant Nutritional Formula

AETNA-CPB-0202, Magnetic Resonance Spectroscopy (MRS)

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