Does T38.5X6A require prior authorization?

No, T38.5X6A does not require prior authorization (high confidence). Covered without prior authorization.

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`T38.5X6A`, Underdosing of other estrogens and progestogens, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When E/M services are reported with allergy testing, medical documentation of the separately identifiable E/M service must be present in the medical record and modifier -25 must be used.
Part B providers must indicate the actual number of tests (one unit per antigen/test) in Box 24G of Form CMS-1500 (paper) or in the service field on EMC claims; the number of tests must also be shown on the claim for MPFSDB payment.
Medical records must document history (including immunologic history), physical exam, antigens chosen, test performance, and interpretation; counseling and prescriptions should be documented and reported as a visit.

Hospitals should report charges for single allergy tests as charges per test and bill the appropriate number of units to describe all tests provided, reflecting APC assignment differences (single tests vs multiple tests).

Medical records must document a complete medical and immunologic history and an appropriate face-to-face physical examination prior to allergy testing.

When in vitro testing is ordered, the medical record must state the indication and document why skin testing is impossible or would be unreliable for that patient.

Key Coverage Criteria

Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.
Standard skin testing is the preferred method when allergy testing is necessary.
When a percutaneous or intracutaneous single test (CPT 95004 or 95024) and sequential/incremental tests (CPT 95017, 95018, 95027) are performed the same day, both code types may be reported only if they are for different allergens or for different dilutions of the same allergen.
CPT code 95060 is payable in office, outpatient hospital (on-campus/off-campus), inpatient hospital, and emergency room settings.
Delayed hypersensitivity skin testing is covered for anergy testing, diagnosing intracellular pathogen infections, and evaluating sensitivity to contact allergens when testing is limited to allergens associated with contact reactions.

3 Active Policies

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

WPS-J8-L36402, Allergy Testing

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T38.5X6A, Underdosing of other estrogens and progestogens, initial encounter