Does Q76.428 require prior authorization?

No, Q76.428 does not require prior authorization (high confidence). Covered without prior authorization.

`Q76.428`, Congenital lordosis, sacral and sacrococcygeal region

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.
Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.

Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
Outpatient alpha-fetoprotein testing is consideredmedically necessaryfor any of the following indications:
Screening for neural tube defects in pregnant persons;or
Evaluation or management of the following conditions:Carcinoma of unknown primary site;orGerm cell tumors;orHepatocellular carcinoma (HCC): diagnosed HCC, suspected HCC, or for those at high risk for HCC;orMediastinal mass;orOvarian cancer;orPelvic mass;orRetroperitoneal mass;orTesticular cancer or suspicious testicular mass;orThymoma or thymic cancer.

ANTHEM-CG-LAB-26, Outpatient Alpha-Fetoprotein Testing

A57206, Billing and Coding: Lumbar MRI

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