Does Q44.6 require prior authorization?

No, Q44.6 does not require prior authorization (high confidence). Covered without prior authorization.

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`Q44.6`, Cystic disease of liver

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.
Rigorous clinical evaluation should precede diagnostic molecular testing.
Disease-specific diagnostic criteria or clinical findings as listed throughout the policy must be documented (e.g., Amsterdam II or revised Bethesda for Lynch syndrome; Schwartz score for LQTS; clinical criteria for Marfan Syndrome [see Appendix]; clinical features lists for Angelman, Prader-Willi, CADASIL, etc.).
For general medical necessity: documentation that all of the following are met: The member displays clinical features, or is at direct risk of inheriting the mutation (pre-symptomatic); and The result of the test will directly impact the treatment being delivered to the member; and After history, physical examination, pedigree analysis, genetic counseling, and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a suspected diagnosis is listed; and Disease-specific criteria met.

Key Coverage Criteria

Loeys-Dietz syndrome (TGFBR1, TGFBR2): Testing medically necessary when: asymptomatic individual has affected first-degree relative with known deleterious mutation (test for familial mutation); or to confirm diagnosis in individual with LDS characteristics (begin with TGFBR2 sequencing, then TGFBR1 if negative).
I42.0 Dilated cardiomyopathy [hereditary]
I49.01 Ventricular fibrillation
I71.01 Dissection of thoracic aorta
Von Hippel-Lindau syndrome (VHL)
Walker-Warburg syndrome (POMGNT1)

4 Active Policies

AETNA-CPB-0140, Genetic Testing

AETNA-CPB-0207, Prolotherapy and Sclerotherapy

AETNA-CPB-0259, Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

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

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For whole exome sequencing: documentation that member and family history have been evaluated by a Board-Certified or Board-Eligible Medical Geneticist; member receives pre- and post-test counseling by an independent provider (e.g., ABMG or ABGC-certified Genetic Counselor or APGN credentialed by GNCC or ANCC); alternate etiologies considered and ruled out when possible; clinical presentation does not fit a well-described syndrome for which single-gene/panel testing is available; WES more efficient than separate single-gene tests/panels; diagnosis cannot be made by standard clinical work-up (excluding invasive procedures); documentation that WES is predicted to have impact on health outcomes (treatment, surveillance, palliative care, reduce diagnostic uncertainty, or inform reproductive counseling).

Q44.6, Cystic disease of liver