Does S36.490S require prior authorization?

No, S36.490S does not require prior authorization (high confidence). Covered without prior authorization.

`S36.490S`, Other injury of duodenum, sequela

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
For decisions about preoperative biliary drainage: documentation of rationale for PBD if performed given evidence that routine PBD may increase infectious complications
Operative and peri-operative records documenting reconstruction technique (antecolic vs retrocolic), use of Braun anastomosis, omental/falciform wraps, stent placement, fibrin patch application, and rationale for such adjuncts (since evidence varies and practices may be individualized)
No explicit 'Documentation Requirements' section is provided in the text. (The policy repeatedly states that codes/procedures are 'covered if selection criteria are met' but does not list the selection criteria.)

Surgical resection of endocrine tumors (gastrinomas) including management of Zollinger-Ellison syndrome (ZES), with and without multiple endocrine neoplasia type 1 (MEN1)
Resection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas
C24.1 Malignant neoplasm of ampulla of Vater
D13.2 Benign neoplasm of duodenum
D13.5 Benign neoplasm of extrahepatic bile ducts
Pancreaticoduodenectomy (also known as Whipple resection) : CPT codes covered if selection criteria are met : 48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple- hyphen type procedure); with pancreatojejunostomy

AETNA-CPB-0365, Pancreaticoduodenectomy (Whipple Resection)

A56421, Billing and Coding: CT of the Abdomen and Pelvis

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