Does G97.1 require prior authorization?

No, G97.1 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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`G97.1`, Other reaction to spinal and lumbar puncture

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

This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.

Key Coverage Criteria

CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
None. Aetna considers intra-oral appliances (e.g., the Nociceptive Trigeminal Inhibition-Tension Suppression System) experimental and investigational for the treatment of headaches and trigeminal neuralgia because the effectiveness of this approach for these indications has not been established.

6 Active Policies

ANTHEM-SURG.00144, Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

AETNA-CPB-0462, Headaches: Nonsurgical Management

AETNA-CPB-0688, Intra-oral Appliances for Headaches and Trigeminal Neuralgia

A56612, Billing and Coding: CT of the Head

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

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G97.1, Other reaction to spinal and lumbar puncture