Does R45.89 require prior authorization?

No, R45.89 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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`R45.89`, Other symptoms and signs involving emotional state

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

Claims must meet the reasonable and necessary requirements described in the related LCD (L35101); providers must retain medical record documentation supporting medical necessity per the LCD.
When billing for services that are not covered, the claim must include the appropriate modifier to indicate non-coverage status.
When a second provider bills a diagnostic interview for a beneficiary they are seeing for the first time, documentation should support that it is the provider's first encounter with the beneficiary.

Activation maps should be registered/ integrated in neuro-navigational systems (e.g., "fMRI data were then registered in a frameless stereotactic neuro-navigational device") when fMRI is used for surgical planning.

Key Coverage Criteria

Diagnostic interview codes (e.g., CPT 90791/90792) are indicated for the initial evaluation of a beneficiary, and a second provider seeing the beneficiary for the first time may report diagnostic interview codes for that initial encounter.
CPT code 96105 is indicated for formal evaluation of aphasia using a standardized instrument (for example, the Boston Diagnostic Aphasia Examination).
HCPCS codes G0017 and G0018 are appropriate for services provided in non-facility places of service other than Office.
fMRI lateralizes language in children with cerebral lesions.
Covered ICD-10 diagnoses when selection criteria are met: C79.31 - C79.49 (Secondary malignant neoplasm of brain and other parts of nervous system).
Aetna considers functional magnetic resonance imaging (fMRI) medically necessary to identify the eloquent cortex in pre-surgical evaluation of persons with brain tumors (except temporal tumors), epilepsy (except temporal neocortical epilepsy), or vascular malformations.

8 Active Policies

NOVITAS-JH-L35101, Psychiatric Codes

A57130, Billing and Coding: Psychiatric Codes

NOVITAS-JL-L35101, Psychiatric Codes

ANTHEM-MED.00138, Wearable Devices for Stress Relief and Management

ANTHEM-CG-LAB-20, Thyroid Testing

AETNA-CPB-0370, Phototherapy for Psychiatric Disorders

AETNA-CPB-0739, Quantitative, Functional and Connectomic Analysis of Brain MRI

ANTHEM-CG-LAB-30, Outpatient Laboratory-based Blood Glucose Testing

`R45.89`, Other symptoms and signs involving emotional state

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

R45.89, Other symptoms and signs involving emotional state

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`R45.89`, Other symptoms and signs involving emotional state