Does F16.959 require prior authorization?

No, F16.959 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`F16.959`, Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Medical record must contain documentation supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM diagnosis code(s) that describe the patient's condition and reasons for the service; claims without a valid ICD-10-CM code will be returned as incomplete.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Key Coverage Criteria

Patient has an underlying physical illness or injury for which the HBAI service is intended.
There is documentation that biopsychosocial factors are significantly affecting treatment or medical management of the illness or injury.
Patient is alert, oriented, and has capacity to understand and respond meaningfully during a face-to-face encounter.
There is a documented need for psychological evaluation or intervention to successfully manage the patient's physical illness and activities of daily living.
The HBAI assessment is not duplicative of other provider assessments.
Reassessment is reasonable only when documentation shows a sufficient change in mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with medical interventions.

20 Active Policies

CGS-J15-L34353, Outpatient Psychiatry and Psychology Services

J15

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

CGS-J18-L34353, Outpatient Psychiatry and Psychology Services

J18

A57480, Billing and Coding: Psychiatry and Psychology Services

WPS-J5-L34616, Psychiatry and Psychology Services

A56937, Billing and Coding: Psychiatry and Psychology Services

A52434, Health and Behavior Assessment/Intervention Medical Policy Article

NGS-J6-L33632, Psychiatry and Psychology Services

WPS-J8-L34616, Psychiatry and Psychology Services

A57780, Billing and Coding: Psychological and Neuropsychological Tests

FIRST_COAST-L34520, Psychological and Neuropsychological Tests

NOVITAS-JH-L35101, Psychiatric Codes

NOVITAS-JH-L35006, Controlled Substance Monitoring and Drugs of Abuse Testing

NOVITAS-JH-L35049, Monitored Anesthesia Care

NGS-JK-L33632, Psychiatry and Psychology Services

NOVITAS-JL-L35101, Psychiatric Codes

A56645, Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

A57130, Billing and Coding: Psychiatric Codes

A57361, Billing and Coding: Monitored Anesthesia Care

`F16.959`, Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

F16.959, Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`F16.959`, Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified