Does N99.3 require prior authorization?

No, N99.3 does not require prior authorization (high confidence). Covered without prior authorization.

`N99.3`, Prolapse of vaginal vault after hysterectomy

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

If MR defecography is proposed, documentation must address the reasons for choosing MR (note: MR defecography is considered investigational for CPB-listed indications and MR-related CPTs are listed as not covered for CPB indications).
Documented chronic constipation as defined in the policy: presence of 2 or more of the following symptoms for at least 3 months: 'Lumpy and/or hard stools at least 1/4 of the time; or Sensation of incomplete evacuation at least 1/4 of the time; or Straining at defecation at least 1/4 of the time; or Two or fewer bowel movements per week.'
Results of anorectal manometry and rectal balloon expulsion test demonstrating negative or inconclusive findings (these tests must have been performed prior to defecography per policy).
Clinical documentation (history/physical, clinical notes, referral) showing suspicion of one or more of the specific causes of impaired defecation listed in the policy: anterior rectocele, enterocele, inappropriate contraction of the puborectalis muscle, or pelvic organ prolapse.

Inappropriate contraction of the puborectalis muscle.
Pelvic organ prolapse.
Covered CPT code (if selection criteria are met): 74270 (Radiologic examination, colon; barium enema, with or without KUB).
ICD-10 codes covered if selection criteria are met:
K59.00 - K59.09 (Constipation) [policy notes: not covered for routine evaluation; covered only if selection criteria met].
K59.4 (Anal spasm [proctalgia fugax] [inappropriate contraction of the puborectalis muscle]).

ANTHEM-CG-MED-84, Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting

AETNA-CPB-0718, Defecography

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