Does E78.019 require prior authorization?

No, E78.019 does not require prior authorization (high confidence). Covered without prior authorization.

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`E78.019`, Familial hypercholesterolemia, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Document the medical necessity for the chosen test frequency in the medical record (preferably on the test report).
Document that any applicable physician supervision requirement is met (preferably on the test report).
Medical record must document a clinical diagnosis and the specific reason for the study to substantiate medical necessity.
Document the specific reason for performing a stress echocardiogram instead of only an electrical (ECG) stress test.

Key Coverage Criteria

Stress testing (exercise or pharmacological, including stress echocardiography) is covered when the results will potentially affect the patient’s treatment plan.
An initial follow-up stress test may be indicated several months after myocardial infarction (MI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA) when clinically appropriate.
A second follow-up stress test may be indicated approximately one year after the first follow-up test following MI, CABG, or PTCA when clinically appropriate.
Patients with silent coronary disease (no reliable signs or symptoms) may require stress testing as often as annually when clinically indicated.
Patients who present with reliable symptoms or signs of coronary artery disease (e.g., angina pectoris) may require stress testing as dictated by symptoms but typically will not require annual testing.
An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.

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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E78.019, Familial hypercholesterolemia, unspecified