Does T85.528A require prior authorization?

No, T85.528A does not require prior authorization (high confidence). Covered without prior authorization.

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`T85.528A`, Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims for covered bariatric surgery must include three diagnosis codes with the primary diagnosis as E66.01, E66.812, or E66.813 and secondary/tertiary diagnoses from the specified ICD-10-CM code groups (group 1 and group 2).
When using CPT 43843 or CPT 43999 to bill a Not Otherwise Classified (NOC) or specific open procedures, include a note identifying the specific test/procedure performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Refer to LCD L35022 for complete reasonable-and-necessary documentation requirements and retain supporting medical records as required by Medicare policy.

Medical record must document failure to maintain healthy weight despite adequate participation in a structured dietary program overseen by an MD/DO, RD or other listed nutrition specialists and include surgeon certification of the patient's efforts.

Key Coverage Criteria

Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
Clinically significant obstructive sleep apnea is an accepted comorbid indication.
Obesity-related hypoventilation is an accepted comorbid indication.
Refractory hyperlipidemia not controllable with diet and maximal lipid-lowering medication is an accepted comorbid indication.

3 Active Policies

NOVITAS-JH-L35022, Bariatric Surgical Management of Morbid Obesity

NOVITAS-JL-L35022, Bariatric Surgical Management of Morbid Obesity

A56422, Billing and Coding: Bariatric Surgical Management of Morbid Obesity

`T85.528A`, Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

T85.528A, Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`T85.528A`, Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter