Does O00.81 require prior authorization?

No, O00.81 does not require prior authorization (high confidence). Covered without prior authorization.

`O00.81`, Other ectopic pregnancy with intrauterine pregnancy

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
Clear clinical indication and the specific diagnostic question for the ultrasound
Documentation of ultrasound findings relevant to the indication (e.g., gestational age, fetal number, viability, placental location)

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
Determination of gestational age
Assessment of fetal number (e.g., multiple gestation)
Assessment of fetal viability
Determination of placental location

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

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