Does I70.628 require prior authorization?

No, I70.628 does not require prior authorization (high confidence). Covered without prior authorization.

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`I70.628`, Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All documentation must be maintained in the patient's medical record, be legible, include complete patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
Every submitted medical record page must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

If the service provider differs from the ordering/referring physician, the performing provider must maintain hard copy documentation of test results and interpretation plus copies of the ordering/referring physician’s order for the studies.

The ordering physician must state the clinical indication and medical necessity for the test in the order, and the referring physician must maintain documentation in the beneficiary's record that the LCD-required conditions for the stress test have been met.

Key Coverage Criteria

Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
Preoperative cardiac stress testing with radionuclide imaging for asymptomatic patients deemed at moderate risk is covered only if the medical record documents at least one of the following: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.
Serum homocysteine testing is covered for evaluation of suspected vitamin B12 (cobalamin) deficiency.
Serum homocysteine testing is covered for risk stratification for the conditions listed in the ICD-10-CM Codes that Support Medical Necessity in LCD L34419.
Serum homocysteine testing is covered for evaluation of suspected folate (vitamin B9) deficiency.
Nail debridement (CPT 11720 or 11721) for mycotic nails is covered when billed with ICD-10-CM B35.1 as the primary diagnosis and one of the following as a secondary diagnosis: L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, or R26.2.

19 Active Policies

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

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

A56758, Billing and Coding: Non-Invasive Vascular Studies

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

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

NGS-J6-L33627, Non-Invasive Vascular Studies

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

FIRST_COAST-L38396, Cardiology Non-emergent Outpatient Stress Testing

A56952, Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing

NOVITAS-JH-L35083, Cardiology Non-emergent Outpatient Stress Testing

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

NGS-JK-L33627, Non-Invasive Vascular Studies

NOVITAS-JL-L35083, Cardiology Non-emergent Outpatient Stress Testing

A56423, Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing

A56680, Billing and Coding: Routine Foot Care

A56775, Billing and Coding: Magnetic Resonance Angiography

A56675, Billing and Coding: Homocysteine Level, Serum

A56476, Billing and Coding: Cardiac Radionuclide Imaging

A60247, Billing and Coding: Endovascular Management for Peripheral Arterial Disease of the Upper and Lower Extremities

`I70.628`, Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity

Prior Authorization

Documentation Required

Key Coverage Criteria

19 Active Policies

Related Codes

Have a follow-up question?

I70.628, Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity

Prior Authorization

Documentation Required

Key Coverage Criteria

19 Active Policies

Related Codes

Have a follow-up question?

`I70.628`, Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity