Does K52.3 require prior authorization?

No, K52.3 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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`K52.3`, Indeterminate colitis

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 submitted CPT/HCPCS code must accurately describe the service performed.
All documentation must be maintained in the patient 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.

Key Coverage Criteria

Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
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.
Capsule endoscopy (CPT 91110, 91111 global) is payable under Medicare Part B when performed in office (POS 11), independent diagnostic testing facility (POS 49), or independent clinic (POS 49).
Technical component codes 91110-TC and 91111-TC are payable under Part B in office (11), IDTF (49), independent clinic (49), federally qualified health center (50), and rural health clinic (72).

20 Active Policies

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J18

CGS-J18-L34081, Endoscopy by Capsule

J18

WPS-J5-L34614

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K52.3, Indeterminate colitis