Does T38.6X5A require prior authorization?

No, T38.6X5A does not require prior authorization (high confidence). Covered without prior authorization.

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`T38.6X5A`, Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's condition and indicate the reason(s) the service was performed; claims without ICD-10-CM codes will be returned.
For diagnostic tests, report the test result on the claim if known; if the result is not known at time of claim, report the symptoms that prompted the test.

Key Coverage Criteria

RAST type tests are covered when medically necessary and supported by the related Local Coverage Determination (LCD) and current medical literature or standards of practice.
Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L34063, RAST Type Tests

J15

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

CGS-J18-L34063, RAST Type Tests

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

A56844, Billing and Coding: RAST Type Tests

NGS-J6-L33591, RAST Type Tests

NGS-J6-L40329, Allergy Diagnostic Testing

WPS-J8-L36402, Allergy Testing

A57531, Billing and Coding: Allergy Testing

FIRST_COAST-L33261, Allergy Testing

NOVITAS-JH-L35049, Monitored Anesthesia Care

NOVITAS-JH-L36241, Allergy Testing

NGS-JK-L40329, Allergy Diagnostic Testing

NGS-JK-L33591, RAST Type Tests

A57361, Billing and Coding: Monitored Anesthesia Care

NOVITAS-JL-L36241, Allergy Testing

`T38.6X5A`, Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T38.6X5A, Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T38.6X5A`, Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter