Does T85.79XA require prior authorization?

No, T85.79XA does not require prior authorization (high confidence). Covered without prior authorization.

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`T85.79XA`, Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The patient’s medical record must document medical necessity supporting the related LCD (L33585), including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A clear clinical indication for the breast sonogram, breast MRI, or ductogram must be documented in both the medical record and the referral order.
The medical record must include a formal written report describing all views completed, the reason for the test, a description of the test, interpretation and results, and the name of the physician to whom the report is being sent.

Key Coverage Criteria

Breast sonography (CPT 76641, 76642) is covered when the medical record documents medical necessity per the related LCD (L33585); if performed bilaterally, report modifier 50 with CPT 76641 or 76642.
Breast MRI is covered only when billed with CPT code 77046, 77047, 77048, or 77049 and when medical necessity is documented per the related LCD (L33585).
Mammary ductogram/galactogram is covered only when billed with CPT 77053 or 77054 and medical necessity is documented per the related LCD (L33585); use CPT 19030 for contrast injection when billed separately.
For Part A facility billing, breast sonography should be billed using CPT 76641/76642; breast MRI may be billed using HCPCS C8903, C8905, C8906, C8908 or CPT 77046/77047; ductography should be billed using CPT 77053 or 77054.
Transesophageal echocardiography (TEE) is indicated when transthoracic echocardiography (TTE) provides inadequate visualization of cardiac anatomy for structures normally visualized by TTE; report ICD-10-CM R93.1 or R93.8 as the primary diagnosis and the cardiac abnormality as a secondary diagnosis.
TEE is indicated when performed during an open chest (intraoperative) procedure; report ICD-10-CM Z01.89 as the primary diagnosis and the reason for the surgical procedure as the secondary diagnosis.

20 Active Policies

CGS-J15-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J15

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L34337, Transesophageal Echocardiography (TEE)

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L34337, Transesophageal Echocardiography (TEE)

J18

CGS-J18-L34181, Ophthalmic Biometry for Intraocular Lens Power Calculation

J18

WPS-J5-L39051, Cosmetic and Reconstructive Surgery

A56916, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

WPS-J5-L34760, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A58774, Billing and Coding: Cosmetic and Reconstructive Surgery

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

NGS-J6-L33585, Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

NGS-J6-L33579, Transesophageal Echocardiography (TEE)

NGS-J6-L33577, Transthoracic Echocardiography (TTE)

A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

A52868, Billing and Coding: Transesophageal Echocardiography (TEE)

A56537, Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

`T85.79XA`, Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T85.79XA, Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T85.79XA`, Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter