Does G47.30 require prior authorization?

No, G47.30 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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`G47.30`, Sleep apnea, 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

The medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each echocardiography service requires a formal written report with interpretation retained in the record and copies of image documentation (paper or electronic) available for review.
A complete study must include M-mode and/or 2D measurements of LV end-diastolic diameter, LV end-systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion, and a qualitative description of LV function, or valid substitutes such as LV volumes, ejection fraction, and mass.
Doppler interrogation must state the modes used and provide both qualitative and quantitative information.

Key Coverage Criteria

Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
Repeat echocardiographic studies are covered to monitor changes in cardiac structure or function when there is a change in clinical status or when disease progression is suspected.
Diagnostic polysomnography or other sleep testing is covered when the patient has symptoms or complaints of one of the conditions listed in LCD L36839.
A single polysomnogram (PSG) with EEG is ordinarily sufficient and covered to evaluate and diagnose suspected obstructive sleep apnea (OSA).
Diagnosis of narcolepsy is ordinarily confirmed by up to three Multiple Sleep Latency Test (MSLT) naps; MSLT (CPT 95805) performed appropriately is covered for this indication.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L36902, Polysomnography and Other Sleep Studies

J15

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L36902, Polysomnography and Other Sleep Studies

J18

WPS-J5-L36839

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G47.30, Sleep apnea, unspecified