Does K28.5 require prior authorization?

No, K28.5 does not require prior authorization (high confidence). Covered without prior authorization.

`K28.5`, Chronic or unspecified gastrojejunal ulcer with perforation

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
Therapeutic EGD is covered for removal of foreign bodies from the esophagus or stomach.
EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
EGD is covered for upper abdominal distress accompanied by a short history of concerning signs or symptoms such as weight loss, anorexia, vomiting, or NSAID/other gastric irritant intake.
EGD is covered for patients older than 40 years who have a significant history of heartburn that recurs after a course of symptomatic therapy.

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

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

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

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