Does R11.2 require prior authorization?

No, R11.2 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`R11.2`, Nausea with vomiting, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Verify and document compliance with applicable NCCI edits and OPPS packaging rules prior to billing.
Include a valid ICD-10-CM diagnosis code on the claim that best describes the patient's condition for which the heavy metal test was performed.
For diagnostic heavy metal tests, report the test result on the claim if known; if the result is not known, report the symptoms that prompted the test.
When required, report the referring/ordering physician's name and NPI on the claim.

Key Coverage Criteria

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Parathormone (parathyroid hormone) testing is covered when medical necessity and reasonable-and-necessary criteria specified in Local Coverage Determination L34018 are met.
For renal dialysis facilities submitting claims for parathormone testing, use diagnosis code N18.6 (end stage renal disease).
Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.

20 Active Policies

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

NGS-J6-L39995, Pharmacogenomic Testing

A56767, Billing and Coding: Heavy Metal Testing

A59915, Billing and Coding: Pharmacogenomic Testing

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R11.2, Nausea with vomiting, unspecified