Does I48.11 require prior authorization?

No, I48.11 does not require prior authorization (high confidence). Covered without prior authorization.

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`I48.11`, Longstanding persistent atrial fibrillation

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Practitioner and/or provider must append modifier -KX to the claim as an attestation that documentation is on file verifying the patient has a symptomatic arrhythmia or high potential for progression requiring a permanent pacemaker for Group 1 and Group 2 diagnoses.
Medical records must include objective diagnostic evidence (eg, ECG, Holter/event monitor, documented asystole or pauses, electrophysiology study, tilt-table testing, or other cardiac monitoring) demonstrating bradyarrhythmia or high‑grade AV block when used to justify pacemaker implantation.
Documentation must show reversible causes of bradycardia have been evaluated and excluded (eg, electrolyte levels, medication review, temperature), or provide rationale why chronic necessary drug therapy causing bradycardia cannot be changed.

Key Coverage Criteria

Documented non-reversible symptomatic bradycardia due to sinus node dysfunction is covered for implantation of a single- or dual-chamber permanent cardiac pacemaker.
Documented non-reversible symptomatic bradycardia due to second-degree or third-degree atrioventricular (AV) block is covered for implantation of a single- or dual-chamber permanent cardiac pacemaker.
Symptomatic bradycardia defined by heart rate <60 beats per minute accompanied by symptoms directly attributable to the slow rate (eg, syncope, seizures, congestive heart failure, dizziness, confusion) supports coverage when non-reversible.
Selected asymptomatic patients may be covered when objective monitoring or electrophysiologic criteria are met and the practitioner attests with modifier -KX (examples include awake asymptomatic patients with asystole >=3.0 seconds or escape rate <40 bpm, AF with pauses >=5 seconds, postoperative AV block not expected to resolve, neuromuscular disease with advanced block, or asymptomatic high-grade block with cardiomegaly or LV dysfunction).
Contractor-determined additional diagnostic indications listed as Group 2 (eg, symptomatic or select symptomatic first-degree AV block with PR >300 ms, bundle branch/fascicular blocks, certain supraventricular tachycardias when pacemaker specifically controls tachycardia, atrial fibrillation/flutter with symptomatic bradycardia from necessary therapy) may be covered when attested with modifier -KX and documentation is on file.
Personal history of sustained ventricular tachycardia (spontaneous or EP-induced) not associated with an acute myocardial infarction and not due to a transient or reversible cause is an indication for ICD implantation.

20 Active Policies

CGS-J15-L33947, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L36139, MolDX: Biomarkers in Cardiovascular Risk Assessment

J15

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I48.11, Longstanding persistent atrial fibrillation