Does I36.0 require prior authorization?

No, I36.0 does not require prior authorization (high confidence). Covered without prior authorization.

`I36.0`, Nonrheumatic tricuspid (valve) stenosis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.

Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
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.

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

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