Does Q64.9 require prior authorization?

No, Q64.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`Q64.9`, Congenital malformation of urinary system, unspecified

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.
Documentation that the member meets the transplanting institution's selection criteria; OR if no institution criteria exist, documentation that both required numeric criteria are met: calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min, AND documented ESRD with current dialysis or expectation of requiring dialysis within the next 12 months.
Record of the Cockcroft-Gault calculation inputs (age, weight in kg, serum creatinine in mg/dL) or directly measured GFR values to support creatinine clearance/GFR determination.

Key Coverage Criteria

Simultaneous pancreas-kidney (SPK) transplantation is medically necessary for members with diabetes and end-stage renal disease (ESRD) who meet the transplanting institution's selection criteria.
Aetna considers SPK and SPLK transplantation medically necessary for persons with certain relative contraindications if the attending physician determines and documents that the potential benefits of SPK or SPLK transplantation outweigh the risks (relative contraindications listed separately).
CPT/HCPCS/Coding context: Specific CPT codes (e.g., 48554 Transplantation of pancreatic allograft; 50360 Renal allotransplantation; donor nephrectomy codes 50300/50320/50547; and others listed) and HCPCS S2065 (Simultaneous pancreas kidney transplantation) are listed as covered if selection criteria are met.
ICD-10 diagnoses listed as covered if selection criteria are met: E10.21 - E10.29; E11.21 - E11.29; E13.21 - E13.29 (Diabetes mellitus with renal manifestations); N18.5 (Chronic kidney disease, Stage V); N18.6 (End stage renal disease).
Simultaneous cadaver-donor pancreas and living-donor kidney (SPLK) transplantation is medically necessary for members with diabetes and ESRD who meet the transplanting institution's selection criteria.
If a transplanting institution has no selection criteria, SPK or SPLK is medically necessary when ALL of the following are met: (1) calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min; AND (2) member has ESRD and requires dialysis or is expected to require dialysis in the next 12 months.

2 Active Policies

AETNA-CPB-0587, Pancreas Kidney Transplantation

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

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Q64.9, Congenital malformation of urinary system, unspecified