Does K55.1 require prior authorization?

No, K55.1 does not require prior authorization (high confidence). Covered without prior authorization.

`K55.1`, Chronic vascular disorders of intestine

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.
For services requiring a referring/ordering physician, the claim must report the referring/ordering physician's name and NPI.

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.
MRA is covered to evaluate blood flow in the internal carotid vessels of the head and neck.
MRA of peripheral arteries of the lower extremities is covered to determine the presence and extent of peripheral vascular disease and may substitute for conventional angiography (CA).
MRA is covered for pre-operative evaluation of patients undergoing elective abdominal aortic aneurysm (AAA) repair when it is comparable to CA for determining extent of AAA and evaluating aortoiliac occlusive disease and renal artery pathology necessary for surgical planning.

CGS-J15-L34084, Transcatheter Infusion Therapy

J15

CGS-J15-L40258, MolDX: Genetic Testing for Hereditary Thrombophilia

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

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