Does R40.0 require prior authorization?

No, R40.0 does not require prior authorization (high confidence). Code is covered without prior authorization.

`R40.0`, Somnolence

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The individualized plan of treatment or diagnosis must be recorded in the patient's medical record in accordance with 42 CFR 412.27(c)(3) and 42 CFR 482.61.
Physician periodic evaluations of the therapeutic program must be documented based on consultations, conferences with therapists, medical record reviews, and regularly scheduled patient interviews (at least once weekly).
The physician's certification period of active treatment must cover all days on which inpatient psychiatric facility services were provided because of the individual's need for active treatment and be documented in the record.
Services by qualified non-physician personnel (social workers, occupational therapists, group therapists, attendants) must be prescribed and directed by a physician and documented to meet the individual's specific needs.

IPF services are 'active treatment' when provided under an individualized treatment or diagnostic plan developed by a physician with appropriate other disciplines based on a thorough evaluation of the patient's strengths and disabilities.
Services expected to reasonably improve the patient's condition or services provided for the purpose of diagnosis qualify as active treatment.
Services supervised and periodically evaluated by a physician (including physician-directed prescriptions and oversight of non-physician therapists) qualify as active treatment.
Psychotherapy, drug therapy (including antidepressants or tranquilizers when other active-treatment elements are present), electroconvulsive therapy, occupational therapy, recreational therapy, and planned milieu therapy qualify as active treatment when expected to result in measurable improvement.
A period of active treatment includes all inpatient days where psychiatric facility services are furnished because of the individual's need for active treatment, including essential periods of observation or temporary discontinuation of therapy.
Patients with progressive physical or mental deterioration (e.g., Alzheimer's disease, Pick's disease) may receive active treatment when services are designed to alleviate specific neurological or life-supportive symptoms and are expected to improve those conditions.

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J15-L34196, Psychiatric Partial Hospitalization Programs

J15

CGS-J15-L34353, Outpatient Psychiatry and Psychology Services

J15

CGS-J15-L34183, Psychiatric Inpatient Hospitalization

J15

CGS-J18-L34353

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