Does G31.1 require prior authorization?

No, G31.1 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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`G31.1`, Senile degeneration of brain, not elsewhere classified

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-L34046, Speech-Language Pathology

J15

CGS-J18-L34046, Speech-Language Pathology

J18

A52434, Health and Behavior Assessment/Intervention Medical Policy Article

A59049, Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions

A57780, Billing and Coding: Psychological and Neuropsychological Tests

FIRST_COAST-L34520, Psychological and Neuropsychological Tests

NOVITAS-JH-L35070, Speech - Language Pathology (SLP) Services: Communication Disorders

NOVITAS-JH-L35101, Psychiatric Codes

A54111, Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders

NOVITAS-JL-L35070, Speech - Language Pathology (SLP) Services: Communication Disorders

A53134, Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions

NOVITAS-JL-L35101, Psychiatric Codes

A57130, Billing and Coding: Psychiatric Codes

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

CIGNA-0567, Serum Folate and Red Blood Cell Folate Testing

A56562, Billing and Coding: Health and Behavior Assessment/Intervention

A56612, Billing and Coding: CT of the Head

A56639, Billing and Coding: Hospice Alzheimer's Disease & Related Disorders

A56641, Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances

A56756, Billing and Coding: Home Health - Psychiatric Care

`G31.1`, Senile degeneration of brain, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

G31.1, Senile degeneration of brain, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`G31.1`, Senile degeneration of brain, not elsewhere classified