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ICD-10-CM Q64.19, Other exstrophy of urinary bladder | No Prior Auth

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`Q64.19`, Other exstrophy of urinary bladder

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.
Chronic sialorrhea — documentation member is refractory to pharmacotherapy (e.g., anticholinergics).
Anal fissures — documentation of failure to first-line therapy such as topical calcium channel blockers or topical nitrates.
Hirschsprung disease with internal sphincter achalasia — documentation that treatment is after endorectal pull-through and refractory to laxative therapy.

Key Coverage Criteria

OnabotulinumtoxinA (Botox) medically necessary indications (initial approval): Achalasia — Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.
Botulinum toxin type A has become 1st-line therapy for Frey's syndrome.
Botulinum toxin type A therapy for blepharospasm
Botulinum toxin for chronic low back pain
Botulinum toxin for Raynaud's phenomenon / ischemic digits
Botulinum toxin for temporomandibular disorders

2 Active Policies

AETNA-CPB-0113, Botulinum Toxin

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

Related Codes

N40.0(2 policies)N80.9(2 policies)N30.10(2 policies)N30.11(2 policies)N40.3(2 policies)N80.00(2 policies)K44.9(2 policies)N82.0(2 policies)

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Services are covered 'if selection criteria are met' — documentation should demonstrate that the applicable selection criteria (as referenced in the policy) are met for the specific product and indication.

Precertification: Providers must obtain precertification for botulinum toxin; call (866) 752-7021 or fax (888) 267-3277; use Statement of Medical Necessity (SMN) precertification forms (Specialty Pharmacy Precertification).