Does Q07.9 require prior authorization?

No, Q07.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`Q07.9`, Congenital malformation of nervous system, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Maintain all documentation in the patient’s medical record; every page must be legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s).
The submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

Speech-language pathology (SLP) services for treatment or evaluation of communication disorders when determined reasonable and necessary per LCD L35070.
Selection and prescription of speech-generating devices should be billed with CPT code 92607.
Adaptation and training for speech-generating devices should be billed with CPT code 92609.
Report group therapy with CPT code 92508 when patients are not receiving direct one-on-one contact and are supervised by the therapist.
Use the appropriate CPT evaluation code for re-evaluations in SLP because CPT does not define a distinct re-evaluation code.
ICD-10 codes covered if selection criteria are met (not all-inclusive): F02.80: Dementia in other diseases classified elsewhere, without behavioral disturbance

5 Active Policies

NOVITAS-JH-L35070, Speech - Language Pathology (SLP) Services: Communication Disorders

NOVITAS-JL-L35070, Speech - Language Pathology (SLP) Services: Communication Disorders

A54111, Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders

CIGNA-0567, Serum Folate and Red Blood Cell Folate Testing

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Use must match one of the medically necessary purposes listed (ambulatory recording to facilitate subsequent expert visual EEG interpretation; continuous EEG monitoring by frequency-trending in OR/ICU; evaluation when neuroimaging and routine EEG are inconclusive for cerebrovascular disease; evaluation of dementia/encephalopathy when diagnosis unresolved after initial clinical evaluation; screening for possible epileptic seizures in high-risk ICU members; screening for spikes/seizures during long-term EEG monitoring; topographic voltage and dipole analysis in pre-surgical evaluations for intractable epilepsy)

Q07.9, Congenital malformation of nervous system, unspecified