Does K61.4 require prior authorization?

No, K61.4 does not require prior authorization (high confidence). Covered without prior authorization.

`K61.4`, Intrasphincteric abscess

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.
The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
Documentation supporting the service must be available to Medicare upon request.

Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
To guide application of cryotherapy or brachytherapy for treatment of prostate cancer;or
To evaluate and stage prostate cancer or rectal cancer;or
Prostate-specific antigen (PSA) level greater than 3.0 ng/ml;or
Transrectal ultrasonography (TRUS) is consideredmedically necessaryforanyof the following indications:
To guide prostate biopsy when prostate cancer is suspected based onanyof the following:Abnormal digital rectal examination (DRE);orProstate-specific antigen (PSA) level greater than 3.0 ng/ml;orMedical history;or

NGS-J6-L33578, Transrectal Ultrasound

A57427, Billing and Coding: Transrectal Ultrasound

NGS-JK-L33578, Transrectal Ultrasound

ANTHEM-CG-RAD-28, Transrectal Ultrasonography

A56421, Billing and Coding: CT of the Abdomen and Pelvis

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