Does P91.61 require prior authorization?

No, P91.61 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`P91.61`, Mild hypoxic ischemic encephalopathy [HIE]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.
Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.

Key Coverage Criteria

CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
Ambulatory electroencephalography (EEG) following completion of a routine EEG is considered medically necessary for the diagnosis and management of seizure activity when ANY of the following criteria is met:
inconclusive routine EEG
suspected epilepsy when the history, clinical examination, and routine EEG is inconclusive
suspected seizures of sleep disturbances

2 Active Policies

CIGNA-0521, Electroencephalography

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

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Clinical documentation supporting one of the listed indications (e.g., inconclusive routine EEG; history and clinical examination documenting suspected epilepsy when routine EEG is inconclusive; suspected seizures of sleep disturbances; confirmed epilepsy with suspected non-epileptic events; need for classification of seizure type for selection/adjustment of anti-epileptic medication; need to exclude non-neurological causes of seizure-like activity; documentation that seizures are precipitated by naturally occurring cyclic events or environmental stimuli not reproducible in clinic).

P91.61, Mild hypoxic ischemic encephalopathy [HIE]