Does I50.9 require prior authorization?

No, I50.9 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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`I50.9`, Heart failure, unspecified

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

Medical documentation supporting reasonable and necessary determination for additional sessions must be included (examples: recent hospital records, office visit notes, dialysis progress notes, MCP visits) when billing 90999 KX.
Follow the WPS GHA LCD L37537 for full documentation requirements and utilization guidelines for frequency of hemodialysis.
For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, use one of the permitted line-item billing approaches consistent with the patient's plan of care and supporting documentation.
Append modifier CG to additional sessions when the facility attests the extra treatment is not reasonable and necessary (CG use is for data analysis and will result in denial of payment for that line).

Key Coverage Criteria

Report each hemodialysis session for ESRD patients on a separate line for claims with dates of service on or after April 1, 2007.
When hemodialysis prescription is 3 sessions per week and each session is furnished, bill each session as CPT 90999 with no modifier for routine conventional dialysis.
For dialysis sessions beyond 3 sessions per week that are reasonable and necessary and supported by medical documentation, bill each additional session as CPT 90999 with modifier KX to be considered for additional payment.
Coverage indications for Coronary Computed Tomography Angiography (CCTA) are defined in the associated Local Coverage Determination LCD L35121; consult LCD L35121 for specific clinical criteria and medical necessity requirements.
BNP testing is reasonable and necessary, when used with other medical data, to distinguish a cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes.
BNP testing may be used to distinguish decompensated congestive heart failure from exacerbation of chronic obstructive pulmonary disease in a symptomatic patient with both chronic CHF and COPD.

20 Active Policies

CGS-J15-L37575, Frequency of Hemodialysis

J15

CGS-J15-L33943, B-type Natriuretic Peptide (BNP) Testing

J15

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L33959

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I50.9, Heart failure, unspecified