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ICD-10-CM O14.00, Mild to moderate pre-eclampsia, unspecified trimester | No Prior Auth

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`O14.00`, Mild to moderate pre-eclampsia, unspecified trimester

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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)
Clinical documentation of history, laboratory abnormalities, or clinical examination supporting suspected anomaly.
Documentation of suspicious findings from a limited or standard ultrasound when 76811 is performed for follow-up.

Key Coverage Criteria

Evaluation of germ cell tumors;or
Testicular cancer or suspicious testicular mass;or
Ovarian cancer;or
Pelvic mass;or
Mediastinal mass;or
Retroperitoneal mass;or

3 Active Policies

ANTHEM-CG-LAB-27, Human Chorionic Gonadotropin Testing

ANTHEM-CG-RAD-26, Maternity Ultrasound in the Outpatient Setting

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

Related Codes

O00.91(3 policies)O16.9(3 policies)A92.5(2 policies)76805(2 policies)76801(2 policies)76811(2 policies)76815(2 policies)76816(2 policies)

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When a second detailed anatomic ultrasound is performed, documentation that a new MFM group assumed care or that a second opinion was required.

Billing must include an appropriate high-risk diagnosis code as specified in Table 4.