Does R06.5 require prior authorization?

No, R06.5 does not require prior authorization (high confidence). Covered without prior authorization.

`R06.5`, Mouth breathing

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
CPT codes 40806, 40819, 41010, 41115, 41520 are covered if selection criteria are met.
HCPCS codes D7960, D7961, D7962 are covered if selection criteria are met.
Lingual or labial frenectomy, frenotomy, or frenuloplasty medically necessary for ankyloglossia when newborn feeding difficulties or childhood articulation problems exist.
ICD-10 P92.01 - P92.9: Feeding problems of newborn (listed as covered diagnoses when selection criteria are met).
ICD-10 Q38.1: Ankyloglossia (listed as a covered diagnosis when selection criteria are met).

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

AETNA-CPB-0116, Frenectomy or Frenotomy for Ankyloglossia

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