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ICD-10-CM O23.00, Infections of kidney in pregnancy, unspecified trimester | No Prior Auth

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`O23.00`, Infections of kidney in pregnancy, unspecified trimester

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Record of specimen type as fresh vaginal discharge.
Documented pH value (numeric) when pH testing performed.
Microscopy findings from both saline and KOH preparations, including presence/absence of motile T. vaginalis, clue cells, yeast, and white blood cells.
Result of whiff/amine test when performed.

Key Coverage Criteria

Outpatient urine culture testing for bacteria is consideredmedically necessaryto evaluate any of the following situations:
Clinical signs or symptoms suggesting urinary tract infection (UTI);or
Abnormal urinalysis suggesting UTI;or
Asymptomatic bacteriuria in pregnant persons;or
Bacteriuria in individuals prior to undergoing an endoscopic urologic procedure;or
Suspected interstitial cystitis or bladder pain syndrome.

3 Active Policies

ANTHEM-CG-LAB-24, Outpatient Urine Culture

AMBETTER-CP.MP.97, Testing for Select Genitourinary Conditions

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

Related Codes

O09.811-O09.819(2 policies)N77.1(2 policies)O09.511-O09.519(2 policies)O09.521-O09.529(2 policies)O16.9(2 policies)O44.20(2 policies)76805(1 policies)76801(1 policies)

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Vaginal Gram stain result with documented Nugent score or Hay/Ison grade when used for diagnosis.

If Gram stain unavailable, documentation that Amsel's Diagnostic Criteria were assessed and that three of the required signs/symptoms were present.