Does R94.02 require prior authorization?

No, R94.02 does not require prior authorization (high confidence). Covered without prior authorization.

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`R94.02`, Abnormal brain scan

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.
Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.

Key Coverage Criteria

CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
Lumbar puncture (CSF testing) to confirm presence of elevated phosphorylated tau (P-tau) and/or elevated total tau (T-tau) and reduced beta amyloid-42 (Aβ42) or a low Aβ42/Aβ40 ratio as determined by the lab assay detected in cerebrospinal fluid (CSF) for the assessment of mild cognitive impairment (MCI) when Alzheimer's disease (AD) is suspected.
Brain magnetic resonance imaging (MRI) for persons on aducanumab-avwa (Aduhelm) or lecanemab-irmb (Leqembi) therapy for the following indications: (a) within one year prior to initiating aducanumab or lecanemab therapy to indicate AD, or (b) to evaluate for evidence of amyloid-related imaging abnormalities (ARIA) prior to the 5th, 7th, 9th, and 12th aducanumab dose or prior to the 5th, 7th, and 14th lecanemab dose (see CPB 0996 and CPB 1026 for details).
Genetic mutation testing for APP, PSEN1, or PSEN2 for members with MCI or mild AD dementia who are less than 50 years of age and who are being considered for enrollment in a clinical trial of aducanumab (Aduhelm) or lecanemab (Leqembi).
Amyloid PET scan indications are referenced (see CPB 0071 - Positron Emission Tomography (PET)) — amyloid PET is handled under CPB 0071.

2 Active Policies

AETNA-CPB-0349, Alzheimer's Disease Tests

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

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R94.02, Abnormal brain scan