Does R39.9 require prior authorization?

No, R39.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`R39.9`, Unspecified symptoms and signs involving the genitourinary system

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

There should be a written treatment plan which must include: the specific diagnosis/conditions to be treated; long- and short-term goals; measurable objectives; the time frame and the frequency of treatment in which the goals and objectives will be achieved.
Patients must be cognitively intact and willing and motivated to learn and practice the specific tasks needed to correct/improve their problems.
Biofeedback must be performed by a licensed healthcare professional or qualified non-physician practitioner (examples given: physical and occupational therapists in independent practice, nurse practitioners, physician assistants, clinical nurse specialists).
Biofeedback must be performed in a clinical setting with continuous one-on-one face-to-face presence of the physician or qualified practitioner during training (documentation should reflect this).

Key Coverage Criteria

Biofeedback performed by a licensed healthcare professional is considered medically necessary for Chronic constipation with dyssynergic defecation (adults only).
Biofeedback performed by a licensed healthcare professional is considered medically necessary for Fecal incontinence for patients with: some degree of rectal sensation; ability to contract the sphincter voluntarily; and failure/intolerance/contraindication of treatment with dietary changes, devices or drugs.
Biofeedback performed by a licensed healthcare professional is considered medically necessary for Stress, urgency, mixed, or overflow urinary incontinence when there is failure/intolerance/contraindication of other nonpharmacologic treatment (e.g., bladder training and/or pelvic floor muscle training [PFMT]) (children and adults).
Biofeedback performed by a licensed healthcare professional is considered medically necessary for Migraine and tension headaches (children and adults) as part of a comprehensive treatment plan.
Biofeedback performed by a licensed healthcare professional is considered medically necessary for Muscle re-education of specific extremity muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness when: patient is diagnosed with stroke, and failure/intolerance/contraindication of conventional treatments (e.g. modalities, massage, soft tissue mobilization, exercise).
Biofeedback performed by a licensed healthcare professional is considered medically necessary for Refractory levator ani syndrome (e.g. proctalgia fugax, chronic anal pain syndrome, anal spasm) with dyssynergic defecation when: condition is not neurological or disease-based, and there is failure/intolerance/contraindication of conservative treatment including high-fiber diet; withdrawal of drugs that cause constipation (e.g., calcium channel blockers, narcotics) or diarrhea (e.g., antibiotics, q [...]

2 Active Policies

ANTHEM-CG-LAB-24, Outpatient Urine Culture

CIGNA-CPG294, Biofeedback

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R39.9, Unspecified symptoms and signs involving the genitourinary system