Does Q85.81 require prior authorization?

No, Q85.81 does not require prior authorization (high confidence). Covered without prior authorization.

Backwork Sign up free

`Q85.81`, PTEN hamartoma tumor syndrome

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
For fundus photography, the medical record must document relevant medical history, physical examination, pertinent diagnostic test results, retention of the photographs, an interpretation/report, whether the pupil was dilated, and which drug was used; records must be legible and available to the carrier.

Key Coverage Criteria

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Fundus photography is covered when medical necessity is documented in the medical record, including relevant history, exam, diagnostic test results, and retention of the photographs and an interpretation/report.
Extended ophthalmoscopy is covered when medical necessity is documented for each eye, including relevant history, physical exam, pertinent diagnostic results, and retinal drawings that meet the policy specifications.
Patients actively receiving intravitreal injections for exudative age-related macular degeneration (ICD H35.3210-H35.3213, H35.3220-H35.3223, H35.3230-H35.3233) may require and are covered for extended ophthalmoscopy.

20 Active Policies

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L34081, Endoscopy by Capsule

J15

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J15-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J15

Have a follow-up question?

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

Ask Backwork about Q85.81 Sign up free

For extended ophthalmoscopy the record must include relevant history, physical exam, pertinent diagnostic results, retinal drawings meeting Appendix A specifications (separate detailed sketch 3-4 inches, labeled, colors preferred), and documentation of the method of examination and pupil dilation/drug; records must be legible and available.

For a diagnosis of glaucoma (ICD H40.001-H40.152) documentation must include a separate detailed optic nerve drawing with an interpretation that affects treatment, and documentation of cupping, disc rim, pallor, slope, and any surrounding pathology.

CGS-J18-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J18

CGS-J18-L34081, Endoscopy by Capsule

J18

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

CGS-J18-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

J18

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

A56394, Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

A56726, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

NGS-J6-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

WPS-J8-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J8-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

NGS-JK-L33567, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

A57071, Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

A57342, Billing and Coding: Diagnostic and Therapeutic Colonoscopy

A58652, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

Q85.81, PTEN hamartoma tumor syndrome