Does S92.919B require prior authorization?

No, S92.919B does not require prior authorization (high confidence). Covered without prior authorization.

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`S92.919B`, Unspecified fracture of unspecified toe(s), initial encounter for open fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of medical indication consistent with ACIP recommendations or policy-specified indications (e.g., routine preventive immunization according to ACIP schedule, pregnancy, catch-up series, wound management).
Immunization history and dates of prior tetanus-, diphtheria-, and pertussis-containing vaccine doses to determine eligibility, intervals (for example, >5 years for wound management vaccine indication, or timing for catch-up schedules and decennial boosters).
For vaccine formulations with manufacturer- or previous-dose–dependent indications (e.g., Kinrix, Quadracel), documentation of prior vaccine brands and doses (e.g., Infanrix, Pediarix, Pentacel, Daptacel) as specified in the policy.

Pregnancy status and gestational age for Tdap in pregnant women (policy: Tdap should be administered at 27–36 weeks’ gestation; coverage noted 'regardless of prior vaccination history' for pregnant women).

Clinical documentation of wound type and whether wound is contaminated/‘dirty’ or other qualifying injury (use of policy-listed ICD-10 wound/injury codes is compatible with coverage).

When tetanus immune globulin (TIG) is administered/provided, documentation that the patient is unvaccinated or has not received a primary tetanus series with a contaminated wound, or that the patient has HIV infection or severe immunodeficiency and a contaminated wound (policy TIG indications).

Key Coverage Criteria

Tenivac (Td) indicated for prevention of tetanus and diphtheria in persons 7 years of age and older (booster every 10 years or as part of 3-shot series if unvaccinated).
Diphtheria, tetanus toxoid, and whole-cell or acellular pertussis vaccines as preventive services according to the recommendations of the Advisory Committee on Immunization Practices (ACIP).
Boostrix (GlaxoSmithKline), a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) as a preventive service for active booster immunization against tetanus, diphtheria, and pertussis as a single dose in individuals 10 years of age and older.
CPT/HCPCS codes for administration (e.g., 90471, +90472) and vaccine product codes (e.g., 90700, 90715, 90696, 90697, 90698, 90696, 90697, 90698, 90723, 90702, 90714) when selection criteria/indications are met (see code table).
ICD-10: Z23 (Encounter for immunization) listed as a covered diagnosis when selection criteria are met.
ICD-10 codes for contaminated wounds / relevant injuries are listed as covered when indicating the need for tetanus-containing immunization (examples/list as provided in the policy): S00.00x+ - S00.97x+; S10.0xx+ - S10.97x+; S20.00x+ - S20.91x+; S30.0xx+ - S30.98x+; S40.011+ - S40.929+; S50.00x+ - S50.919+; S60.00x+ - S60.949+; S70.00x+ - S70.929+; S80.00x+ - S80.929+; S90.00x+ - S90.936+; S01.00x+ - S01.95x+; S11.011+ - S11.95x+; S21.001+ - S21.95x+; S31.000+ - S31.839+; S41.001+ - S41.159+; S5 [...]

1 Active Policy

AETNA-CPB-0653, Diphtheria, Tetanus, and Pertussis Vaccines

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S92.919B, Unspecified fracture of unspecified toe(s), initial encounter for open fracture