Does R53.82 require prior authorization?

No, R53.82 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`R53.82`, Chronic fatigue, unspecified

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 applicable LCD coverage criteria are met and that the test is expected to influence treatment; include relevant history, exam findings, problems/diagnoses, and data (labs, imaging) that support the ordering decision.
The laboratory or billing provider must retain the physician requisition that specifies the diagnosis or condition (ICD-10-CM code) warranting the test.
Performing laboratories must have, and provide when requested, documentation such as lab accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records.
For laboratory-developed tests (LDTs) or protocols, documentation when requested must include the diagnostic assay, laboratory/manufacturer, names of comparable assays (if relevant), assay description, analytical validity, clinical validity, and clinical utility evidence.

Key Coverage Criteria

MS testing is covered when performed in accordance with the applicable Local Coverage Determination (LCD) coverage guidelines for monoclonal gammopathy.
Mass spectrometry (MS) testing is covered when the medical record documents that the testing is expected to influence the treatment or management of the condition for which the test is ordered.
No specific clinical indications are listed in this article; follow the Local Coverage Determination (LCD) L39400 for indications for magnesium testing or services.
No covered indications are explicitly listed in this CPB. The bulletin primarily designates adoptive immunotherapy and cellular therapy approaches described below as experimental and investigational (i.e., not supported as effective).
Note / exception: "This policy does not apply to lifileucel for the treatment of advanced melanoma." (lifileucel is handled separately).
For CAR T therapies and specific agent coverage consult the related CPBs referenced (e.g., CPB 0920 Kymriah, CPB 0924 Yescarta, CPB 0980 Tecartus, CPB 0986 Breyanzi, CPB 0992 Abecma, CPB 1007 Carvykti).

17 Active Policies

A58921, Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

NGS-J6-L39189, Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

NGS-JK-L39189, Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)

AETNA-CPB-0049, Nutritional Counseling

AETNA-CPB-0158

Have a follow-up question?

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

Ask Backwork about R53.82 Sign up free

R53.82, Chronic fatigue, unspecified