Does K58.9 require prior authorization?

No, K58.9 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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`K58.9`, Irritable bowel syndrome, unspecified

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.
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).
Professional component codes 91110-26 and 91111-26 are payable under Part B in office (11), outpatient hospital (19 and 22), inpatient hospital (21), independent clinic (49), and public health clinic (71).
When capsule endoscopy is normal but compelling symptoms persist, irritable bowel syndrome or abdominal pain diagnosis codes K58.0, K58.9, R10.11-R10.13, R10.2, R10.31-R10.33, or R10.84 are on the list of covered diagnoses and may be used.
Report Patency Capsule Testing using CPT 91299 and enter 'Patency Capsule Testing' in Item 19 of the CMS-1500 (or electronic equivalent); the ingestion of the capsule is part of the test.

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

A55937

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K58.9, Irritable bowel syndrome, unspecified