Does L56.1 require prior authorization?

No, L56.1 does not require prior authorization (high confidence). Covered without prior authorization.

`L56.1`, Drug photoallergic response

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
Clinical documentation of clinically significant allergic symptoms and that testing is part of a complete diagnostic evaluation.

Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
Allergy testing to determine immunologic sensitivity for immediate (IgE-mediated) hypersensitivity.
Allergy testing to determine immunologic sensitivity for delayed (cell-mediated) hypersensitivity.

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

NGS-J6-L40329, Allergy Diagnostic Testing

NGS-JK-L40329, Allergy Diagnostic Testing

AMBETTER-CP.MP.100

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