Does I63.431 require prior authorization?

No, I63.431 does not require prior authorization (high confidence). Covered without prior authorization.

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`I63.431`, Cerebral infarction due to embolism of right posterior cerebral artery

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

A referral must be on record for each non-invasive vascular study performed; a referral for one type of study does not serve as referral for all other tests.
Medical record documentation must support medical necessity of the study, including signs/symptoms, physical findings, ABI/chart copies, abnormal physiologic study results, and rationale when multiple or simultaneous studies are performed.
Credentialing and accreditation documentation must be maintained and available: physicians must demonstrate competency; technologists should hold credentials (e.g., RPVI, RVT, RCVT, RVS, ARRT in vascular sonography); facilities should hold accreditation (e.g., ACR Vascular Ultrasound Program, ICAVL); transcutaneous oxygen measurements may be performed by NBDHMT-certified individuals (CHT or CHRN).

Key Coverage Criteria

Non-invasive vascular studies are medically necessary when the ordering physician reasonably expects the test outcome will impact clinical management and there are significant signs or symptoms of arterial or venous disease, the information is necessary for medical/surgical management, and the test is not redundant of other diagnostics.
Cerebrovascular arterial studies (duplex or Doppler with spectral analysis) are indicated for patients with one or more of: cervical bruit, amaurosis fugax, focal cerebral/ocular TIA (e.g., unilateral weakness, sensory loss, slurred speech), syncope suggestive of vertebrobasilar/bilateral carotid disease, recent neurologic/cerebrovascular event, pre-major cardiac/vascular surgery with bruit or prior event, post-carotid endarterectomy (outside global period), pulsatile neck mass, blunt/penetratin [...]
Transcranial Doppler (TCD) is indicated to detect/evaluate severe extracranial stenosis (>=60% diameter reduction) or major basal intracranial artery stenosis (>=50% diameter reduction), cerebral vasospasm after subarachnoid hemorrhage, intracranial hemodynamic abnormalities in suspected brain death, intraoperative/perioperative monitoring during carotid endarterectomy, evaluation of cerebral embolization, assessment of collateral circulation in severe stenosis/occlusion when needed for care, st [...]
Peripheral arterial non-invasive examinations are medically necessary to establish level/degree of arterial occlusive disease when (1) significant signs/symptoms of limb ischemia are present (acute ischemia: sudden severe pain, coldness, numbness, pallor; chronic: intermittent claudication, rest pain, diminished pulses, ulceration, gangrene) and (2) the patient is a candidate for invasive/surgical intervention.
Pre-surgical conduit assessment of upper extremity/radial artery(ies) (duplex/physiologic testing) is indicated before use as arterial conduits for CABG or other bypass when clinical evaluation necessitates objective vessel assessment.
Peripheral venous studies are indicated for DVT when the patient has clinical signs/symptoms of DVT or PE (e.g., edema, tenderness, erythema, hemoptysis, chest pain, dyspnea), unexplained lower extremity edema post-major surgery/trauma/progressive illness, or unexplained lower extremity pain (non-skeletal), and the patient is a candidate for anticoagulation, thrombolysis, or invasive therapy.

20 Active Policies

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

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

J15

CGS-J15-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

CGS-J18-L36139, MolDX: Biomarkers in Cardiovascular Risk Assessment

J18

CGS-J18-L35906, Somatosensory Testing

J18

CGS-J18-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

WPS-J5-L34624, Somatosensory Testing

WPS-J5-L34636, Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)

WPS-J5-L34623, Intraoperative Neurophysiological Testing

WPS-J5-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

WPS-J5-L34615, Visual Fields

WPS-J5-L35753, Non-Invasive Cerebrovascular Studies

`I63.431`, Cerebral infarction due to embolism of right posterior cerebral artery

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

I63.431, Cerebral infarction due to embolism of right posterior cerebral artery

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`I63.431`, Cerebral infarction due to embolism of right posterior cerebral artery