Does K21.01 require prior authorization?

No, K21.01 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`K21.01`, Gastro-esophageal reflux disease with esophagitis, with 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.
Claims for covered bariatric surgery must include three diagnosis codes with the primary diagnosis as E66.01, E66.812, or E66.813 and secondary/tertiary diagnoses from the specified ICD-10-CM code groups (group 1 and group 2).

Key Coverage Criteria

Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
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.

20 Active Policies

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

WPS-J5-L34659, Endoscopic Treatment of GERD

A56395, Billing and Coding: Endoscopic Treatment of GERD

A59915, Billing and Coding: Pharmacogenomic Testing

NGS-J6-L39995, Pharmacogenomic Testing

WPS-J8-L34659, Endoscopic Treatment of GERD

A57145, Billing and Coding: Surgical Management of Morbid Obesity

A58812, Billing and Coding: Pharmacogenomics Testing

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L39073, Pharmacogenomics Testing

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L33411, Surgical Management of Morbid Obesity

NOVITAS-JH-L39063, Pharmacogenomics Testing

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

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

NGS-JK-L39995, Pharmacogenomic Testing

A56422, Billing and Coding: Bariatric Surgical Management of Morbid Obesity

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

A57414, Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

A58801, Billing and Coding: Pharmacogenomics Testing

`K21.01`, Gastro-esophageal reflux disease with esophagitis, with bleeding

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

K21.01, Gastro-esophageal reflux disease with esophagitis, with bleeding

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`K21.01`, Gastro-esophageal reflux disease with esophagitis, with bleeding