Does R19.5 require prior authorization?

No, R19.5 does not require prior authorization (high confidence). Covered without prior authorization.

`R19.5`, Other fecal abnormalities

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Colon capsule endoscopy (CCE) may be billed when an instrument (optical) colonoscopy was attempted but was incomplete, documented by ICD-10-CM code Z53.8.
CCE may be billed when optical colonoscopy is contraindicated as determined by a board-certified or board-eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training, documented by ICD-10-CM code Z53.09.
All uses of CCE must meet the reasonable and necessary requirements of Local Coverage Determination L38571.

CGS-J15-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

J15

CGS-J15-L38777, Colon Capsule Endoscopy (CCE)

J15

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J15-L34081, Endoscopy by Capsule

J15

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