Does T78.111A require prior authorization?

No, T78.111A does not require prior authorization (high confidence). Covered without prior authorization.

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`T78.111A`, Other adverse food reaction due to milk and dairy products with reactivity to baked milk, 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.

Prior to testing there must be evidence that a history was obtained indicating possible allergy and that attempts were made to narrow the area of investigation so that the minimal necessary skin tests were selected.

The record must indicate which allergy test(s) were used, the interpretation(s), and measurement (in mm) of wheal and erythema responses or a standardized grading system for in vivo testing, as applicable.

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 and dates of service.

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.
Allergy testing is covered when the medical record contains documented history obtained prior to testing that indicates the possible presence of allergy.
Allergy testing is covered when the history and examination show that attempts were made to narrow the area of investigation so that the minimal number of necessary skin tests will be performed.
Allergy testing is covered when the selection of antigens for testing is explicitly based on the patient-specific history and physician or non-physician practitioner examination.
Percutaneous prick/puncture (scratch, puncture, prick) skin testing is medically reasonable and necessary for evaluation of IgE-mediated hypersensitivity to inhalants, foods, Hymenoptera (stinging insects), chemicals, and specific drugs (e.g., penicillins, macromolecular agents).

9 Active Policies

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

NGS-J6-L40329, Allergy Diagnostic Testing

A57531, Billing and Coding: Allergy Testing

FIRST_COAST-L33261, Allergy Testing

NOVITAS-JH-L36241, Allergy Testing

NGS-JK-L40329, Allergy Diagnostic Testing

NOVITAS-JL-L36241, Allergy Testing

A56558, Billing and Coding: Allergy Testing

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T78.111A, Other adverse food reaction due to milk and dairy products with reactivity to baked milk, initial encounter