Does J35.03 require prior authorization?

No, J35.03 does not require prior authorization (high confidence). Covered without prior authorization.

`J35.03`, Chronic tonsillitis and adenoiditis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
When E/M services are reported with allergy testing, medical documentation of the separately identifiable E/M service must be present in the medical record and modifier -25 must be used.

Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

WPS-J8-L36402, Allergy Testing

ANTHEM-CG-SURG-113, Tonsillectomy with or without Adenoidectomy for Adults

A57181, Billing and Coding: Allergy Testing

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