Does Q39.5 require prior authorization?

No, Q39.5 does not require prior authorization (high confidence). Covered without prior authorization.

`Q39.5`, Congenital dilatation of esophagus

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
This billing/coding guideline complements LCD L33459 (Computerized Axial Tomography (CT), Thorax); follow the LCD for clinical coverage and any required documentation or prior authorization rules.

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
Peroral endoscopic myotomy (POEM) is consideredmedically necessaryfor individuals whenallof the following criteria are met:The individual has a diagnosis of primary achalasia;andPOEM is being proposed as an alternative to pneumatic dilation or myotomy (open or laparoscopic);andEckardt symptom score is greater than 3.
The individual has a diagnosis of primary achalasia;and
POEM is being proposed as an alternative to pneumatic dilation or myotomy (open or laparoscopic);and
Eckardt symptom score is greater than 3.

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

NOVITAS-JH-L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

A57414, Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

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