Does I70.538 require prior authorization?

No, I70.538 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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`I70.538`, Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg

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

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.

Key Coverage Criteria

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).
Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.

20 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

WPS-J5-L35761, Non-Invasive Peripheral Arterial Vascular Studies

A56232, Billing and Coding: Foot Care

WPS-J5-L37228, Wound Care

A57590, Billing and Coding: Non-Coronary Vascular Stents

A55909, Billing and Coding: Wound Care

WPS-J5-L35998, Non-Coronary Vascular Stents

A57593, Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies

A56747, Billing and Coding: Magnetic Resonance Angiography (MRA)

A56566, Billing and Coding: Outpatient Physical and Occupational Therapy Services

A56758, Billing and Coding: Non-Invasive Vascular Studies

NGS-J6-L33633, Magnetic Resonance Angiography (MRA)

NGS-J6-L33627, Non-Invasive Vascular Studies

A52850, Billing and Coding: Cardiac Catheterization and Coronary Angiography

NGS-J6-L33557, Cardiac Catheterization and Coronary Angiography

WPS-J8-L35998, Non-Coronary Vascular Stents

WPS-J8-L35761, Non-Invasive Peripheral Arterial Vascular Studies

`I70.538`, Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

I70.538, Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`I70.538`, Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg