Does F51.9 require prior authorization?

No, F51.9 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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`F51.9`, Sleep disorder not due to a substance or known physiological condition, 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.

For physicians, clinical nurse specialists, or nurse practitioners performing these services, use Evaluation & Management or Preventive Medicine codes; services for evaluation/treatment of mental illness should be coded with psychiatric CPT codes (90791-90899) and when both psychiatric and HBAI services are provided, report the predominant service.

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.

10 Active Policies

CGS-J15-L34183, Psychiatric Inpatient Hospitalization

J15

CGS-J15-L34196, Psychiatric Partial Hospitalization Programs

J15

CGS-J18-L34183, Psychiatric Inpatient Hospitalization

J18

CGS-J18-L34196, Psychiatric Partial Hospitalization Programs

J18

A52434, Health and Behavior Assessment/Intervention Medical Policy Article

A57780, Billing and Coding: Psychological and Neuropsychological Tests

FIRST_COAST-L34520, Psychological and Neuropsychological Tests

A57052, Billing and Coding: Psychiatric Inpatient Hospitalization

A57053, Billing and Coding: Psychiatric Partial Hospitalization Programs

AETNA-CPB-0019, Holter Monitors

`F51.9`, Sleep disorder not due to a substance or known physiological condition, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

F51.9, Sleep disorder not due to a substance or known physiological condition, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

10 Active Policies

Related Codes

Have a follow-up question?

`F51.9`, Sleep disorder not due to a substance or known physiological condition, unspecified