Does R31.21 require prior authorization?

No, R31.21 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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`R31.21`, Asymptomatic microscopic hematuria

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

Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
Claims must use CPT 88120 or 88121 as appropriate, report 1 unit of service, and include the appropriate ICD-10 diagnosis code.

Key Coverage Criteria

Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
FISH bladder tumor marker testing (CPT 88120 or 88121) is covered when performed using validated assays (e.g., UroVysion) on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis.
FISH bladder tumor marker testing (CPT 88120 or 88121) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder (urothelial) carcinoma.
For high-risk patients with persistent hematuria and a negative initial FISH after a comprehensive diagnostic workup with no tumor identified, one repeat FISH in conjunction with cystoscopy is considered reasonable and necessary within 1 year of the original attempted diagnosis.
Diagnostic abdominal aortography and renal angiography are covered when they meet the reasonable and necessary clinical requirements specified in LCD L35092.

20 Active Policies

CGS-J15-L36975, Bladder/Urothelial Tumor Markers

J15

CGS-J18-L36975, Bladder/Urothelial Tumor Markers

J18

A57636, Billing and Coding: Duplex Scanning

A57056, Billing and Coding: Aortography and Peripheral Angiography

FIRST_COAST-L33674

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R31.21, Asymptomatic microscopic hematuria