Does I67.4 require prior authorization?

No, I67.4 does not require prior authorization (high confidence). Covered without prior authorization.

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`I67.4`, Hypertensive encephalopathy

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.

Key Coverage Criteria

Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Billing and coding guidance applies to laparoscopic sleeve gastrectomy (sleeve gastrectomy) performed for severe obesity and is intended to complement LCD L34576.
Use this policy's billing/coding rules when submitting claims for laparoscopic sleeve gastrectomy; follow the clinical indication criteria in LCD L34576 for medical necessity determinations.

20 Active Policies

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

WPS-J5-L34615, Visual Fields

A57592, Billing and Coding: Non-Invasive Cerebrovascular Studies

A57483, Billing and Coding: Visual Fields

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I67.4, Hypertensive encephalopathy