Does I85.11 require prior authorization?

No, I85.11 does not require prior authorization (high confidence). Covered without prior authorization.

`I85.11`, Secondary esophageal varices with bleeding

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
For CID codes (T38.895*/T43.215*/T43.225*/T50.995*), the medical record must document the specific chemotherapy agent(s) causing the diarrhea and prior antidiarrheal treatments that have been ineffective.
For VIPoma diagnosis codes (C25.4, C26.0, D13.7, D13.91, D13.99), the medical record must document that the patient’s diagnosis is VIPoma.

Octreotide is covered for chemotherapy-induced diarrhea (CID) when claim includes ICD-10-CM codes T38.895A/T38.895D/T38.895S, T43.215A/T43.215D/T43.215S, T43.225A/T43.225D/T43.225S, or T50.995A/T50.995D/T50.995S and the medical record documents the chemotherapy agent(s) causing the CID and prior antidiarrheal treatments that became ineffective.
Octreotide is covered for treatment of VIPoma when claim includes ICD-10-CM codes C25.4, C26.0, D13.7, D13.91, or D13.99 and the medical record documents that the patient’s diagnosis is VIPoma.
Octreotide may be considered when ICD-10-CM code R79.89 is submitted if the medical record documents abnormal clinical or laboratory findings that led to suspicion of VIPoma.
Octreotide may be considered when ICD-10-CM code R94.7 is submitted if the medical record documents an abnormal octreotide scan that led to suspicion of VIPoma.
Wireless capsule endoscopy of the small bowel (including esophagus through ileum) is billed with CPT 91110 when clinically indicated.
Wireless capsule endoscopy limited to the esophagus is billed with CPT 91111 when clinically indicated.

CGS-J15-L34084, Transcatheter Infusion Therapy

J15

CGS-J18-L34084, Transcatheter Infusion Therapy

J18

A56704, Billing and Coding: Wireless Capsule Endoscopy

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

Ask Backwork about documentation requirements, denial risks, or coverage in your state.