Does H61.21 require prior authorization?

No, H61.21 does not require prior authorization (high confidence). Covered without prior authorization.

`H61.21`, Impacted cerumen, right ear

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient medical record must include the ordering provider's assessment related to the patient's complaint for that visit.
Medical records must contain relevant medical history and results of pertinent tests/procedures; for diagnostic tests report the result if known, otherwise report the symptoms prompting the test.
Office visit records and operative reports must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
When an ABN is used for anticipated denials, the beneficiary should sign Form CMS-R-131 to accept financial responsibility; for Part A MAC claims, occurrence code 32 and the date of the ABN are required.

Medically necessary removal of impacted cerumen requiring a physician's skill is covered when removal by a non-physician poses an unacceptable risk of complications such as tympanic membrane perforation.
Removal requiring physician skill is indicated when the tympanic membrane cannot be observed (e.g., total occlusion or impaction).
Removal requiring physician skill is indicated for overt medical contraindications such as anatomical abnormalities, prior surgical modifications of the ear canal, or presence of infection risk that increase complication risk.
Removal requiring physician skill is indicated when medical conditions pose undue risk of excessive bleeding (e.g., patient on anticoagulants).
Removal requiring physician skill is indicated when cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.
Payment is allowed for medically necessary removal of symptomatic impacted cerumen (i.e., when symptoms such as hearing loss, pain, itching, cough, dizziness, vertigo, or tinnitus are present).

CGS-J15-L33945, Cerumen (Earwax) Removal

J15

CGS-J18-L33945, Cerumen (Earwax) Removal

J18

A56454, Billing and Coding: Cerumen (Earwax) Removal

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