Does E80.4 require prior authorization?

No, E80.4 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E80.4`, Gilbert syndrome

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Relevant laboratory data used to calculate serum biomarker panels (as applicable) and dates of labs.
No additional explicit documentation requirements (e.g., required prior labs, imaging, or clinical notes) are specified in this document excerpt.
Documentation of the clinical diagnosis that justifies the test (e.g., chronic hepatitis C or B, NASH/NAFLD, hereditary hemochromatosis, primary sclerosing cholangitis, other chronic liver disease) — ICD code(s) should support the indication.
Clinical rationale/indication statement in the medical record specifying the intended purpose (e.g., distinguishing cirrhosis vs non‑cirrhosis, follow‑up of PSC, detection/prognosis of fibrosis in NASH).

Noninvasive prognostic assessment (risk stratification) in chronic liver disease
Assessment of advanced fibrosis/portal hypertension and as adjunct in evaluating esophageal varices or portal hypertension
Use of transient elastography (FibroScan) to measure liver stiffness for staging fibrosis and tracking changes during HCV treatment
Use of serum biomarker panels (e.g., FibroTest/FibroSure, ActiTest, Hepascore, APRI, FIB-4, hyaluronic acid, hyaluronate-related models) for prediction of fibrosis/cirrhosis
Pediatric assessment of liver stiffness and fibrosis where feasibility and correlation with other tests are demonstrated
Use of quantitative multiparametric MRI (e.g., LiverMultiScan, multiparametric hepatic MRI) for quantitation of liver disease components (fibrosis, steatosis, inflammation) and aiding NASH diagnosis

AMBETTER-CG-Pharmacogenetics-2025.1-Version-B, Concert Genetic Testing: Pharmacogenetics (Version B)

AETNA-CPB-0690, Noninvasive Tests for Hepatic Fibrosis

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