Does Q87.418 require prior authorization?

Yes, Q87.418 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

`Q87.418`, Marfan syndrome with other cardiovascular manifestations

ICD-10-CM

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation of the qualifications of personnel performing TEE should be available upon request.
For diagnostic TEEs, report the test result if known; if not known, report the symptoms that prompted the test.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim.
Maintain copies of image documentation (paper or tape) and include all appropriate measurements; Doppler interrogations must state modes used and provide qualitative and quantitative data.

Transesophageal echocardiography (TEE) is indicated when transthoracic echocardiography (TTE) provides inadequate visualization of cardiac anatomy for structures normally visualized by TTE; report ICD-10-CM R93.1 or R93.8 as the primary diagnosis and the cardiac abnormality as a secondary diagnosis.
TEE is indicated when performed during an open chest (intraoperative) procedure; report ICD-10-CM Z01.89 as the primary diagnosis and the reason for the surgical procedure as the secondary diagnosis.
Use CPT 93315, 93316, or 93317 for evaluation of congenital cardiac anomalies (these codes are reserved for congenital anomalies only).
CPT 93355 is indicated to report TEE services performed during transcatheter intracardiac therapies and includes probe passage, image acquisition/interpretation, intra-procedural manipulation to guide sizing/placement, assessment of adequacy and complications, and final report.
3D imaging (CPT 93319) and CT/MR fusion or related add-on imaging (CPT 76376, 76377) are allowable when billed as add-on services with their listed base TEE imaging codes.
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.

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

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

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

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