Does K31.5 require prior authorization?

No, K31.5 does not require prior authorization (high confidence). Covered without prior authorization.

`K31.5`, Obstruction of duodenum

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
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.

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.
Screening EGD for persons with symptomatic pernicious anemia to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer).
Screening EGD for persons with cirrhosis and portal hypertension but no prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3, or Child's class B or C disease.
Diagnostic EGD for evaluation of dyspepsia symptoms in persons who have undergone non-invasive testing for H. pylori, whose symptoms persist despite eradication of H. pylori, and who have failed an appropriate therapeutic trial (e.g., PPI with/without prokinetic, antidepressant).
Diagnostic EGD for evaluation of dyspepsia in persons who are H. pylori negative and who have undergone an appropriate trial of PPI therapy (appropriate trial = 2-4 week course of standard dose once daily PPI).

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L33583, 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.