Does T86.20 require prior authorization?

Yes, T86.20 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

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`T86.20`, Unspecified complication of heart transplant

ICD-10-CM

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation Required

The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.

Key Coverage Criteria

Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
Cardiovascular nuclear medicine testing is reimbursable for risk assessment or re-evaluation in asymptomatic patients or patients with stable symptoms who have known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, provided the patient has not undergone a revascularization procedure within the prior 2 years.
Blood pool scan to assess left ventricular ejection fraction prior to implantation of an implantable cardioverter-defibrillator (ICD) or biventricular pacemaker is covered when the medical record documents the intended plan for device insertion and the test result.
Simultaneous cardiac function studies using the first-pass technique performed with perfusion imaging (CPT 78451-78454) and reported with CPT 78472 and add-on 78496 are covered when the formal report documents that first-pass cardiac function studies were performed and the laboratory is equipped to perform them.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L40140, MolDX: Molecular Testing for Solid Organ Allograft Rejection

J15

CGS-J15-L40139, MolDX: Molecular Testing for Solid Organ Allograft Rejection

J15

CGS-J15-L38582, MolDX: Molecular Testing for Solid Organ Allograft Rejection

J15

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T86.20, Unspecified complication of heart transplant