Does E78.011 require prior authorization?

No, E78.011 does not require prior authorization (high confidence). Covered without prior authorization.

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`E78.011`, Heterozygous familial hypercholesterolemia [HeFH]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Maintain all documentation in the patient's medical record and make it available to the contractor upon request; every page must be legible and include appropriate patient identification (e.g., full name, dates of service).
Medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care.
The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Medical record must include history and physical documenting comorbid conditions, an operative report with a detailed procedure note, and office/progress notes showing unsuccessful medical treatment for obesity.

Key Coverage Criteria

For covered laparoscopic restrictive procedures that require port replacement, bill CPT code 43771, 43772, or 43773.
Follow the LCD L33411 reasonable and necessary requirements for surgical management of morbid obesity when determining coverage.
Germline pharmacogenomic (PGx) testing is covered when the test results have established clinical utility to guide management of a specific drug therapy for the Medicare beneficiary.
CPT 81418 (drug metabolism genomic sequence analysis panel) is covered when the panel tests at least 6 genes and includes CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis.
A single-gene or single-allele test ordered by a treating clinician is covered even if the laboratory operationally assays additional genes on the same platform, provided coverage is limited to the single gene/allele component that was reasonable and necessary.
Germline testing that includes genetic content previously untested in the same beneficiary may be covered if the remaining, non-duplicative components demonstrate established clinical utility.

20 Active Policies

CGS-J15-L36139, MolDX: Biomarkers in Cardiovascular Risk Assessment

J15

CGS-J15-L40199, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

J15

CGS-J18-L36139, MolDX: Biomarkers in Cardiovascular Risk Assessment

J18

CGS-J18-L40199, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

J18

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E78.011, Heterozygous familial hypercholesterolemia [HeFH]