Does T78.111S require prior authorization?

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

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

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.

The medical record must document the ordering provider's assessment related to the patient's complaint prompting external ocular photography, including relevant medical history and physical exam findings supporting medical necessity.

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.
External ocular photography is covered when ordered by an authorized/referring provider to document, diagnose, or monitor an ocular condition and when medical record documentation supports medical necessity.
External ocular photographs are covered to track changes in a patient's ocular condition provided changes are documented in writing and compared to prior photographs when available.
Technical (TC) and professional (26) components of external ocular photography are payable under Part B when billed with the appropriate modifier and performed in allowable places of service as specified by Medicare.
Allergy testing is covered when the medical record contains documented history obtained prior to testing that indicates the possible presence of allergy.

12 Active Policies

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J18-L34393, Ocular Photography - External

J18

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

A57068, Billing and Coding: Ocular Photography - External

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