Does R97.20 require prior authorization?

No, R97.20 does not require prior authorization (high confidence). Covered without prior authorization.

`R97.20`, Elevated prostate specific antigen [PSA]

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The submitted medical record must support the use of the selected ICD-10-CM code(s).
The submitted CPT/HCPCS code must accurately describe the service performed.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name and dates of service).

Coverage and medical necessity for the 4Kscore test follow Local Coverage Determination L37798; refer to LCD L37798 for specific reasonable and necessary indications.
4Kscore testing is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L37792.
Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
Molecular biomarker testing to risk-stratify patients who are at increased risk for prostate cancer as allowed by LCD L38985.
Molecular biomarker tests to risk-stratify patients at increased risk for prostate cancer are covered when they meet the clinical indications and medical necessity criteria specified in MolDX LCD L38997.
Molecular biomarker testing to risk-stratify patients at increased risk for prostate cancer when allowed by MolDX Local Coverage Determination L39042.

CGS-J15-L39284, Prostate Cancer Detection with IsoPSAÂ®

J15

CGS-J15-L38997, MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J15

CGS-J18-L38997, MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J18

CGS-J18-L39284, Prostate Cancer Detection with IsoPSAÂ®

J18

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