Does T78.04XA require prior authorization?

No, T78.04XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T78.04XA`, Anaphylactic reaction due to fruits and vegetables, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include appropriate patient identification (e.g., complete name, dates of service).
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

Allergy testing is covered when the medical record documents a history indicating the possible presence of allergy and the clinician selected a minimal number of tests/antigens based on patient-specific history and physician examination.
Allergy testing is covered when the medical record documents the test(s) used, the interpretation(s), and objective measurement of reaction size (wheal and erythema in mm) or a standardized in vivo grading system.
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.

20 Active Policies

CGS-J15-L34063, RAST Type Tests

J15

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L34063, RAST Type Tests

J18

CGS-J18-L40325, Allergy Diagnostic Testing

J18

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

NGS-J6-L33591, RAST Type Tests

NGS-J6-L40329, Allergy Diagnostic Testing

A56844, Billing and Coding: RAST Type Tests

WPS-J8-L36402, Allergy Testing

A57531, Billing and Coding: Allergy Testing

FIRST_COAST-L33261, Allergy Testing

NOVITAS-JH-L36241, Allergy Testing

NOVITAS-JH-L35049, Monitored Anesthesia Care

NGS-JK-L40329, Allergy Diagnostic Testing

NGS-JK-L33591, RAST Type Tests

NOVITAS-JL-L35049, Monitored Anesthesia Care

A56558, Billing and Coding: Allergy Testing

A57361, Billing and Coding: Monitored Anesthesia Care

NOVITAS-JL-L36241, Allergy Testing

`T78.04XA`, Anaphylactic reaction due to fruits and vegetables, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T78.04XA, Anaphylactic reaction due to fruits and vegetables, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T78.04XA`, Anaphylactic reaction due to fruits and vegetables, initial encounter