Does K21.00 require prior authorization?

No, K21.00 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`K21.00`, Gastro-esophageal reflux disease with esophagitis, without bleeding

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The patient's medical record must contain documentation that fully supports medical necessity per LCD L34659, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation supporting the service must be available to the Contractor upon request.
The patient's medical record must contain documentation that fully supports medical necessity for services included within the LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Key Coverage Criteria

Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
Services for select minimally invasive GERD procedures are covered when medical necessity is met as defined in the associated Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
For covered laparoscopic restrictive procedures that require port replacement, bill CPT code 43771, 43772, or 43773.
Follow the LCD L33411 reasonable and necessary requirements for surgical management of morbid obesity when determining coverage.
Germline pharmacogenomic (PGx) testing is covered when the test results have established clinical utility to guide management of a specific drug therapy for the Medicare beneficiary.

20 Active Policies

A56395, Billing and Coding: Endoscopic Treatment of GERD

A59121, Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia

WPS-J5-L34659, Endoscopic Treatment of GERD

A56863, Billing and Coding: Select Minimally Invasive GERD Procedures

NGS-J6-L39995, Pharmacogenomic Testing

A59915, Billing and Coding: Pharmacogenomic Testing

NGS-J6-L35080, Select Minimally Invasive GERD Procedures

WPS-J8-L34659, Endoscopic Treatment of GERD

A58812, Billing and Coding: Pharmacogenomics Testing

FIRST_COAST-L33411, Surgical Management of Morbid Obesity

A57145, Billing and Coding: Surgical Management of Morbid Obesity

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L39073, Pharmacogenomics Testing

NOVITAS-JH-L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

NOVITAS-JH-L39063, Pharmacogenomics Testing

NOVITAS-JH-L35022, Bariatric Surgical Management of Morbid Obesity

NGS-JK-L35080, Select Minimally Invasive GERD Procedures

NGS-JK-L39995, Pharmacogenomic Testing

NOVITAS-JL-L39063, Pharmacogenomics Testing

`K21.00`, Gastro-esophageal reflux disease with esophagitis, without bleeding

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

K21.00, Gastro-esophageal reflux disease with esophagitis, without bleeding

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`K21.00`, Gastro-esophageal reflux disease with esophagitis, without bleeding