Does G04.81 require prior authorization?

No, G04.81 does not require prior authorization (high confidence). Covered without prior authorization.

`G04.81`, Other encephalitis and encephalomyelitis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must contain documentation that fully supports the medical necessity for the visual fields testing in accordance with the applicable LCD.
Documentation should include relevant medical history, a physical examination, and results of pertinent diagnostic tests or procedures supporting the need for visual fields testing.
The diagnosis code(s) reported on the claim must best describe the patient's condition for which the visual fields testing was performed.
Refer to NCCI and OPPS requirements prior to billing Medicare to ensure coding compliance and to determine any bundling or packaging edits.

IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
Coverage requires documentation that the immune globulin therapy is reasonable and necessary in accordance with LCD L34007 and applicable NCDs.
Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT® or PLA code and an accompanying ICD-10-CM diagnosis that documents medical necessity in the patient record.
FDA-cleared/approved molecular infectious disease tests performed consistent with their intended use are covered without a DEX Z-code when billed with an appropriate supporting ICD-10-CM code.
A panel is a single test (single unit of service UOS=1) and is covered as one service even if it reports multiple pathogens or targets.
Testing for additional organisms not included in a billed panel is covered when ordered in addition to the panel and supported by documentation in the medical record.

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J15-L38920, Off-label Use of Rituximab and Rituximab Biosimilars

J15

CGS-J18-L34394, Visual Fields Testing

J18

Ask Backwork about documentation requirements, denial risks, or coverage in your state.