Does Q89.7 require prior authorization?

No, Q89.7 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`Q89.7`, Multiple congenital malformations, not elsewhere classified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each echocardiography service requires a formal written report with interpretation retained in the record and copies of image documentation (paper or electronic) available for review.
A complete study must include M-mode and/or 2D measurements of LV end-diastolic diameter, LV end-systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion, and a qualitative description of LV function, or valid substitutes such as LV volumes, ejection fraction, and mass.
Doppler interrogation must state the modes used and provide both qualitative and quantitative information.

Key Coverage Criteria

Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
Repeat echocardiographic studies are covered to monitor changes in cardiac structure or function when there is a change in clinical status or when disease progression is suspected.
Echocardiograms performed as part of the CAMZYOS REMS program are covered when billed with modifier KX and all REMS program requirements are met for patients with NYHA Class II–III obstructive hypertrophic cardiomyopathy (I42.1).
Non-stress transthoracic echocardiography (TTE) in adults (age 18 and older) considered medically necessary when consistent with ACC Appropriate Use Criteria (AUC) 'Appropriate Care' category (scores 7-9) for: Multimodality Imaging in Cardiovascular Evaluation of Patients Undergoing Nonemergent, Noncardiac Surgery (ACC/Doherty, et al., 2024); Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease (Sachdeva, et al., 2020); Multimodality Imaging in the Assessment [...]
Non-stress TTE considered medically necessary when consistent with ACC/AHA Guidelines (Class I and/or IIa) including: Guideline for the Diagnosis and Management of Hypertrophic Cardiomyopathy (Ommen, et al., 2024); Guideline for the Diagnosis and Management of Atrial Fibrillation (Joglar, et al., 2023); Guideline for the Diagnosis and Management of Aortic Disease (2022); Guideline for the Management of Heart Failure (Heidenreich, et al., 2022); Guideline for the Evaluation and Diagnosis of Chest [...]

8 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

NGS-JK-L33577

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Q89.7, Multiple congenital malformations, not elsewhere classified