Does I80.259 require prior authorization?

No, I80.259 does not require prior authorization (high confidence). Covered without prior authorization.

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`I80.259`, Phlebitis and thrombophlebitis of unspecified calf muscular vein

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For ICD-10-CM codes designated with an asterisk, the patient must be under the active care of a MD/DO who documents the condition and the claim must include the attending physician's name and NPI in CMS-1500 blocks 17/17B, the date patient was last seen (DPLS) in block 19, and the complicating systemic disease in block 21.
All claims for routine foot care based on a systemic condition must include a billing indicator modifier Q7, Q8, or Q9 as appropriate to be considered for payment.
Mycotic nail services should be coded with ICD-10-CM B35.1 as primary and one of the listed secondary diagnosis codes (L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, R26.2); systemic condition modifiers are not required for these mycotic nail–based services.

Key Coverage Criteria

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.
Routine foot care services are covered when the patient has one of the specified systemic conditions (e.g., diabetes mellitus; arteriosclerosis obliterans; Buerger's disease; chronic thrombophlebitis; peripheral neuropathies of the feet including those associated with malnutrition, alcoholism, malabsorption, pernicious anemia, carcinoma, drugs/toxins, multiple sclerosis, uremia, traumatic injury, leprosy/neurosyphilis, hereditary disorders including hereditary sensory radicular neuropathy, Fabry [...]
A presumption of coverage for routine foot care exists when the physician rendering the service documents and bills using modifier Q7 (one Class A finding), Q8 (two Class B findings), or Q9 (one Class B plus two Class C findings) and a systemic condition diagnosis from the listed conditions is present.
Non-invasive vascular diagnostic tests are covered when ordered by the treating practitioner or a consulting physician who will use the results to manage the beneficiary's specific medical problem.
A documented referral/order must be on record for each individual non-invasive vascular study performed for coverage to apply.
Cerebrovascular arterial duplex follow-up is covered annually for stenosis 20–49% (diameter reduction).

11 Active Policies

CGS-J15-L34246, Routine Foot Care and Debridement of Nails

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

CGS-J18-L34246, Routine Foot Care and Debridement of Nails

J18

A57594

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I80.259, Phlebitis and thrombophlebitis of unspecified calf muscular vein