Does Q68.1 require prior authorization?

No, Q68.1 does not require prior authorization (high confidence). Covered without prior authorization.

`Q68.1`, Congenital deformity of finger(s) and hand

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

ICD-10-CM diagnosis code(s) documenting the current or past pressure ulcer as listed in the policy's "ICD-10-CM Diagnosis Codes That Support Medical Necessity" section
Clinical documentation in the medical record verifying presence or history of a pressure ulcer and its location corresponding to the seating contact area
Comprehensive, written evaluation by a licensed/certified medical professional (PT or OT) that clearly explains why a prefabricated seating system is not sufficient to meet seating and positioning needs.
Documentation that the member meets all criteria for the applicable prefabricated seat cushion or prefabricated positioning back cushion.

General use seat cushion (E2601, E2602) and general use wheelchair back cushion (E2611, E2612) for an approved manual or power wheelchair with a sling or solid seat or back.
Skin-protection seat cushion (E2603, E2604, E2622, E2623) for an approved manual or power wheelchair with a sling or solid seat/back when additional clinical criteria are met.
Current pressure ulcer on the area of contact with the seating surface
Past history of a pressure ulcer on the area of contact with the seating surface
Absent or impaired sensation in the area of contact with the seating surface.
Inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury (quadriplegia or paraplegia), other spinal cord disease, multiple sclerosis or other demyelinating disease, cerebral palsy (including athetoid cerebral palsy), anterior horn cell diseases including amyotrophic lateral sclerosis, post‑polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, dem [...]

AMBETTER-CP.MP.99, Wheelchair Seating

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