Does R65.10 require prior authorization?

No, R65.10 does not require prior authorization (high confidence). Covered without prior authorization.

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`R65.10`, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

An interpretation and report must be a complete, separately identifiable written report addressing findings, relevant clinical issues, comparative data (when available), and must be included in the medical record.
The patient's medical record must be legible and clearly document the reasonableness and necessity of the ECG and show that the service was necessary for at least one covered condition in the policy.
A laboratory or portable X‑ray supplier that furnishes an ECG must retain the referring physician’s written order and the identity of the employee who took the tracing.

An ECG furnished on an emergency basis by a laboratory or portable X‑ray supplier requires a physician to be in attendance at the time the service was performed or immediately thereafter to support payment.

Supportive documentation must justify multiple ECGs for acute ischemic episodes or unstable conditions and demonstrate medical necessity when more than one ECG is performed on the same day or more than once annually.

- von Willebrand factor antigen (VWF:Ag), VWF activity measures (RCoF, collagen binding), VWF multimer analysis where available

Key Coverage Criteria

An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
Home-based ECG services (including additional payment above the base ECG amount for transportation) are covered when there is a documented medical need to perform the ECG in the patient's home, typically for homebound or bed-confined patients.
A second professional component (PC) interpretation may be paid when a second physician’s substantially greater expertise is necessary and reasonable to clarify a questionable or confusing ECG finding and contributes substantially to diagnosis or treatment.
Covered diagnoses (ICD-10) if selection criteria are met: M31.19 Other thrombotic microangiopathy.

2 Active Policies

AETNA-CPB-0780, ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP)

A57326, Billing and Coding: Electrocardiograms

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R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction