Does K11.5 require prior authorization?

No, K11.5 does not require prior authorization (high confidence). Covered without prior authorization.

`K11.5`, Sialolithiasis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.
Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.

CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
Sialolithiasis (salivary gland/duct stones) of the major salivary glands (submandibular and parotid glands).
Use of CPT 70486 (CT maxillofacial without contrast) and CPT 76536 (ultrasound, soft tissues of head and neck) when performed for the indications listed in this CPB.
ICD-10 diagnoses covered if selection criteria are met: K11.20 - K11.23 (sialoadenitis [chronic]) and K11.5 (sialolithiasis).
Stones in which a simple transoral surgical approach is not possible (typically stones in the proximal ducts or in the salivary glands themselves) or when transoral removal fails (UpToDate quote: "For patients in whom a simple transoral surgical approach is not possible (typically stones in the proximal ducts or in the salivary glands themselves) or fails, extracorporeal lithotripsy appears to be effective for stones that are intraductal and less than 7 mm.").

AETNA-CPB-0716, Sialolithiasis (Salivary Stones)

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

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