Does F78.A1 require prior authorization?

No, F78.A1 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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`F78.A1`, SYNGAP1-related intellectual disability

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.
If initial assessment or reassessment is completed over multiple encounters, the date of service should be the date the interview was finalized 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.

15 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

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F78.A1, SYNGAP1-related intellectual disability