Does G43.011 require prior authorization?

No, G43.011 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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`G43.011`, Migraine without aura, intractable, with status migrainosus

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

When the service is performed in a hospital inpatient or outpatient setting, use modifier -26 to indicate the professional component.
Billing and coding must adhere to the coverage indications, limitations, and medical necessity criteria described in the associated LCD L34615 Visual Fields; follow that LCD for clinical eligibility and documentation requirements.
Prior to billing Medicare, verify applicable code combinations and correct coding guidelines with the CCI (Correct Coding Initiative).

Key Coverage Criteria

Taped and un-taped visual field testing count as one unit of service for MUE (medically unlikely edits) purposes.
Global visual field services (technical plus professional) are payable under Medicare Part B when billed in place of service: Office (11), Nursing Facility (32), and Independent Clinic (49).
The technical component of visual field testing is payable under Medicare Part B when billed in place of service: Office (11), Nursing Facility (32), Independent Clinic (49), Federally Qualified Health Center (50), and Rural Health Clinic (72).
The professional component of visual field testing is payable under Medicare Part B when billed in place of service: Office (11), Off-campus Outpatient Hospital (19), Inpatient Hospital (21), On-campus Outpatient Hospital (22), Emergency Room (23), Skilled Nursing Facility (31), Nursing Facility (32), Independent Clinic (49), and Comprehensive Outpatient Rehabilitation Facility (62).
Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
Peripheral nerve destruction using radiofrequency ablation or glycerol rhizotomy is considered medically necessary for treatment of trigeminal neuralgia refractory to other alternative treatments (e.g., medication, microdecompression).

20 Active Policies

CGS-J15-L39856, Botulinum Toxin Injections

J15

CGS-J15-L39857, Botulinum Toxin Injections

J15

CGS-J18-L39856, Botulinum Toxin Injections

J18

CGS-J18-L39857, Botulinum Toxin Injections

J18

WPS-J5-L39909, Botulinum Toxin Injections

WPS-J5-L34615, Visual Fields

WPS-J5-L39908, Botulinum Toxin Injections

A57483, Billing and Coding: Visual Fields

WPS-J5-L40381, Botulinum Toxin Injections

NGS-J6-L39832, Botulinum Toxin Injections

WPS-J8-L40381, Botulinum Toxin Injections

WPS-J8-L34615, Visual Fields

WPS-J8-L39909, Botulinum Toxin Injections

WPS-J8-L39908, Botulinum Toxin Injections

FIRST_COAST-L33766, Visual Field Examination

A57637, Billing and Coding: Visual Field Examination

NGS-JK-L39832, Botulinum Toxin Injections

A59809, Billing and Coding: Botulinum Toxin Injections

AMBETTER-CP.VP.63, Visual Field Testing

CIGNA-0525, Peripheral Nerve Destruction for Pain Conditions

`G43.011`, Migraine without aura, intractable, with status migrainosus

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

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G43.011, Migraine without aura, intractable, with status migrainosus

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`G43.011`, Migraine without aura, intractable, with status migrainosus