Does P36.9 require prior authorization?

No, P36.9 does not require prior authorization (high confidence). Covered without prior authorization.

`P36.9`, Bacterial sepsis of newborn, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claims must follow the complementary Local Coverage Determination (LCD L34430) and, when CPT 97000–97799 are used by PT/OT, must include documentation that the services meet the coverage and documentation requirements for physical or occupational therapy.
When submitting claims, linkage to an appropriate covered ICD-10 diagnosis code (e.g., I50.x for heart failure, J40–J47.x for chronic lower respiratory disease, R06.0x for dyspnea when used to distinguish HF from pulmonary disease) should be documented.
If CPT 83880 is billed, documentation should demonstrate that selection criteria for the covered indications (as stated in the policy) are met (clinical notes, emergency/urgent care evaluation, hospital admission notes, imaging or other cardiac testing as applicable).

Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
Measurement of plasma brain natriuretic peptide (BNP) to differentiate dyspnea due to heart failure from pulmonary disease (i.e., in patients presenting with dyspnea where heart failure versus pulmonary cause is in the differential).
NT-proBNP has certain diagnostic value for pulmonary arterial hypertension (PAH) secondary to systemic sclerosis (SSc-PAH) due to its better specificity and moderate sensitivity.
Measurement of plasma BNP to determine prognosis or disease severity in chronic heart failure.
Measurement of plasma BNP upon hospital admission to determine prognosis in persons with acutely decompensated heart failure.
CPT 83880 (natriuretic peptide) is covered if selection criteria are met (test covered as natriuretic peptide testing).

ANTHEM-CG-LAB-24, Outpatient Urine Culture

ANTHEM-CG-MED-49, Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

AETNA-CPB-0518, Nitric Oxide, Inhalational (INO)

AETNA-CPB-0618, Brain Natriuretic Peptide Testing

A56717, Billing and Coding: Respiratory Therapy (Respiratory Care)

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