Does T50.996S require prior authorization?

No, T50.996S does not require prior authorization (high confidence). Covered without prior authorization.

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`T50.996S`, Underdosing of other drugs, medicaments and biological substances, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For anticoagulation alternatives (e.g., argatroban), documentation of indication for alternative anticoagulation (e.g., HIT or AT deficiency) and target monitoring strategy (aPTT/ACT targets).
No documentation requirements are specified in this document chunk. The excerpt is a reference list and does not include required medical record, test result, or clinical documentation statements.
When ECMO is requested as a bridge (to transplant or to durable mechanical circulatory support): documentation of intent (bridge to heart, liver, lung or heart-lung transplantation or to durable mechanical circulatory support) and short-term intent (hours to a few days) as appropriate.

For neonates: documentation that the neonate meets all selection criteria — explicit recorded diagnosis from the policy list (e.g., congenital diaphragmatic hernia; hyaline membrane disease; meconium aspiration; persistent fetal circulation; possible cardiac anomaly; refractory neonatal septic shock; respiratory distress syndrome; uncontrollable air leak), documented gestational age (>= 34 weeks), documented birth weight (>= 2,000 grams), and documented age at time of ECMO (< 10 days, preferably < 7 days).

For children and adults: documentation of the diagnosis from the covered list (e.g., ARDS, primary graft failure after transplant, pulmonary contusion, refractory pediatric septic shock, smoke inhalation, myocarditis, cardiogenic shock, refractory VT/VF, etc.) and documentation that risk of death is very high despite optimal conventional therapy (notes of prior/contemporaneous maximal conventional management measures and failure of those measures).

Documentation that contraindications are considered/absent where applicable (e.g., absence of necrotizing pneumonia, absence of multiple organ failure beyond respiratory/cardiac failure, absence of irreversible neurologic injury or metastatic disease, duration of mechanical ventilation prior to ECMO ≤ 10 days), or rationale if exceptions are being considered.

Key Coverage Criteria

P29.30 - P29.38 Persistent fetal circulation
Neonates: ECMO in neonates who meet all of the following criteria: Diagnosis of any of the following: Congenital diaphragmatic hernia; or Hyaline membrane disease; or Meconium aspiration; or Persistent fetal circulation; or Possible cardiac anomaly; or Refractory neonatal septic shock; or Respiratory distress syndrome; or Uncontrollable air leak; and Gestational age of at least 34 weeks; and Birth weight of 2,000 grams or greater; and Age less than 10 days (preferably less than 7 days).
Children and adults: ECMO and extracorporeal life support (ECLS) for children and adults with any of the following diagnoses when the risk of death is very high despite optimal conventional therapy: Adult respiratory distress syndrome (ARDS); or As a short-term (i.e., hours to a few days) bridge to heart, liver, lung or heart-lung transplantation; or As a short-term bridge to durable mechanical circulatory support; or Following heart surgery to ease transition from cardiopulmonary bypass to vent [...]
33947 initiation, veno-arterial
I47.20, I47.21, I47.29 Ventricular tachycardia
I49.01 Ventricular fibrillation

`T50.996S`, Underdosing of other drugs, medicaments and biological substances, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

T50.996S, Underdosing of other drugs, medicaments and biological substances, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

`T50.996S`, Underdosing of other drugs, medicaments and biological substances, sequela