Does R11.16 require prior authorization?

No, R11.16 does not require prior authorization (high confidence). Covered without prior authorization.

`R11.16`, Cannabis hyperemesis syndrome

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.

Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
Upper gastrointestinal endoscopy (EGD) is covered for persistent upper abdominal distress that continues despite an appropriate trial of therapy.
EGD is covered for upper abdominal distress associated with signs suggesting serious organic disease, e.g., prolonged anorexia or weight loss.

NOVITAS-JH-L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

A57414, Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

NOVITAS-JL-L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

A59186, Billing and Coding: Magnesium

A56421

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