Covered without prior authorization (high confidence)
Documentation Required
For chemical hair analysis to be covered: documentation of clinical indication consistent with suspected chronic arsenic poisoning (for example, relevant signs/symptoms and/or use of covered ICD-10 codes such as T57.0X1A - T57.0X4S or Z13.88) and that selection criteria are met (policy states 'CPT codes covered if selection criteria are met').
For microscopic evaluation of hair structure (CPT 96902) to be covered: documentation that the test is being performed 'as part of the work-up of members with alopecia or abnormal-appearing or abnormally growing hair' and use of appropriate covered ICD-10 codes (L65.0 - L65.9; L67.0; L67.8 - L67.9; L73.1; L73.8 - L73.9).
CPT 96902 must be performed on hairs 'plucked or clipped by the examiner (excluding hair collected by the patient)' (text included in CPT description in policy).
Key Coverage Criteria
ICD-10 codes covered if selection criteria are met for chemical hair analysis (arsenic): T37.8X1A - T37.96XS; T57.0X1A - T57.0X4S; Z13.88 (Encounter for screening for disorder due to exposure contaminants [suspected chronic arsenic poisoning]).
ICD-10 codes covered if selection criteria are met for microscopic hair evaluation (trichogram): L65.0 - L65.9; L67.0, L67.8 - L67.9; L73.1, L73.8 - L73.9.
Chemical hair analysis for diagnosis of suspected chronic arsenic poisoning (see covered ICD-10 codes such as T57.0X1A - T57.0X4S and Z13.88).
Microscopic evaluation of hair structure (trichogram) as part of the work-up of members with alopecia or abnormal-appearing or abnormally growing hair.
CPT codes covered if selection criteria are met: 82175 (Arsenic) and 83015 (Heavy metal; qualitative, any number of analytes) — when used for covered indications (see above).
CPT 96902 (Microscopic examination of hairs plucked or clipped by the examiner ...) when used for covered hair/follicular disorders (see covered ICD-10 codes L65.0-L65.9, L67.0, L67.8-L67.9, L73.1, L73.8-L73.9).
Claims/testing should use the covered CPT/ICD-10 codes listed in the policy (e.g., CPT 82175, 83015 for chemical hair analysis when selection criteria are met; CPT 96902 for trichogram) and must not bill HCPCS P2031 for indications covered in this CPB (P2031 is listed as not covered).
Although not stated as a formal checklist, clinical records should document environmental/occupational exposure history or other clinical rationale supporting testing for chronic arsenic exposure because the policy limits chemical hair analysis coverage to suspected chronic arsenic poisoning.