Does E78.5 require prior authorization?

No, E78.5 does not require prior authorization (high confidence). Covered without prior authorization.

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`E78.5`, Hyperlipidemia, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims for covered bariatric surgery must include three diagnosis codes with the primary diagnosis as E66.01, E66.812, or E66.813 and secondary/tertiary diagnoses from the specified ICD-10-CM code groups (group 1 and group 2).
When using CPT 43843 or CPT 43999 to bill a Not Otherwise Classified (NOC) or specific open procedures, include a note identifying the specific test/procedure performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Refer to LCD L35022 for complete reasonable-and-necessary documentation requirements and retain supporting medical records as required by Medicare policy.
Medical record must document suspected B12 or folate deficiency or the specific ICD-10-CM code from LCD L34419 supporting risk stratification medical necessity.

Key Coverage Criteria

Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
Serum homocysteine testing is covered for evaluation of suspected vitamin B12 (cobalamin) deficiency.
Serum homocysteine testing is covered for risk stratification for the conditions listed in the ICD-10-CM Codes that Support Medical Necessity in LCD L34419.
Serum homocysteine testing is covered for evaluation of suspected folate (vitamin B9) deficiency.

19 Active Policies

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

J15

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

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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E78.5, Hyperlipidemia, unspecified