Does G90.01 require prior authorization?

No, G90.01 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`G90.01`, Carotid sinus syncope

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

Bradycardia due to essential long-term drug therapy may be covered with Modifier -KX when no acceptable alternative exists; documentation of the drug therapy and lack of alternatives must be on file.
Objective diagnostic documentation (e.g., ECG/Holter/monitoring showing heart rate, asystole duration, pauses, electrophysiologic study results, tilt-table testing, and surgical notes) should be maintained to support attestation and coding.
Practitioners must attest with Modifier -KX that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression requiring a permanent pacemaker for Groups I and II.
Group III (conditions not addressed by NCD or contractor) requires attestation with Modifier -SC when billed.

Key Coverage Criteria

Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to second-degree and/or third-degree atrioventricular (AV) block.
Contractor-allowed (Group II) indications covered with attestation include symptomatic AV block, symptomatic first-degree AV block with PR interval >300 ms, and bundle branch/fascicular blocks when symptomatic or otherwise meeting contractor criteria.
Pacemaker implantation is allowed when used specifically to control supraventricular tachycardia (SVT) that is reproducibly terminated by pacing after failure or intolerance of catheter ablation and/or medical therapy.
Pacemaker implantation is allowed for atrial fibrillation/atrial flutter with symptomatic bradycardia that is due to necessary medical therapy (when no acceptable alternative exists), with attestation.
Pacemaker implantation is allowed for hypersensitive carotid sinus syndrome or neurocardiogenic syncope when there is a cardioinhibitory response of ≥3 seconds or significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or on tilt-table testing.

20 Active Policies

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J15-L40243, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J15-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J18-L40243, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J18

Have a follow-up question?

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

Ask Backwork about G90.01 Sign up free

G90.01, Carotid sinus syncope