Does P13.0 require prior authorization?

No, P13.0 does not require prior authorization (high confidence). Covered without prior authorization.

`P13.0`, Fracture of skull due to birth injury

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.

The infant is at least three (3) months of age but not greater than twelve (12) months of age;and
The use of an adjustable cranial orthosis is consideredmedicallynecessaryin the post-operative management of infants following endoscopic repair of craniosynostosis.
The use of cranial orthoses is consideredmedically necessaryas an adjunct to surgical treatment of synostotic skull deformity.
I. The initial use of cranial orthoses is consideredreconstructiveto treat non-synostotic skull deformity (including plagiocephaly, scaphocephaly, and brachycephaly) when the individual meets ALL the following criteria (A and B and C):
Documented failure of at least two (2) months of conservative therapy which includes either (1) or (2) below:Two (2) months of physical therapy for infants with associated cervical motion restriction (which may also be referred to as head preference, head rotation, head tilt, or chin rotation) which includes the following:Initial assessment of range of motion;andFinal assessment of range of motion;orTwo (2) months of home management with repositioning for infants without cervical motion restrict [...]
Two (2) months of physical therapy for infants with associated cervical motion restriction (which may also be referred to as head preference, head rotation, head tilt, or chin rotation) which includes the following:Initial assessment of range of motion;andFinal assessment of range of motion;or

ANTHEM-GL-C159218, CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthoses)

A56612, Billing and Coding: CT of the Head

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