Does Q43.9 require prior authorization?

No, Q43.9 does not require prior authorization (high confidence). Covered without prior authorization.

`Q43.9`, Congenital malformation of intestine, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.
When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.
For high-risk post-surgical follow-up at 1 year (with continued 24-month screening eligibility), report HCPCS code G0105 as the appropriate screening/high-risk colonoscopy code.

Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
To guide application of cryotherapy or brachytherapy for treatment of prostate cancer;or
To evaluate and stage prostate cancer or rectal cancer;or
Prostate-specific antigen (PSA) level greater than 3.0 ng/ml;or
Transrectal ultrasonography (TRUS) is consideredmedically necessaryforanyof the following indications:

ANTHEM-CG-RAD-28, Transrectal Ultrasonography

A56421, Billing and Coding: CT of the Abdomen and Pelvis

A56632, Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

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