Does K51.213 require prior authorization?

No, K51.213 does not require prior authorization (high confidence). Covered without prior authorization.

`K51.213`, Ulcerative (chronic) proctitis with fistula

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L33996, Vitamin D Assay Testing

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L39038

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