Does Z00.01 require prior authorization?

No, Z00.01 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z00.01`, Encounter for general adult medical examination with abnormal findings

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

When colonoscopy is performed after a positive non-invasive test: documentation of colonoscopy findings, polypectomy/pathology results, and follow-up plan is required (implied throughout text).
For CF-specific recommendations: documentation of CF diagnosis and use of CF-specific intensive bowel preparation is expected when following CF Foundation recommendations (text).
Screening is considered medically necessary when tests are 'recommended by their physician' (physician recommendation documented in the medical record).

For biopsy of lower GI tract, specific specimen counts and sampling sites must be met and documented: Microscopic colitis - documentation of 8 or more biopsies with 2 or more from each of ascending, transverse, descending, and sigmoid colon; Inflammatory bowel disease (diagnosis) - documentation of 2 or more biopsies from 5 different locations, including ileum and rectum; IBD dysplasia surveillance - documentation of targeted biopsies plus 4-quadrant biopsies every 10 cm for pancolitis or segmental 4-quadrant biopsies every 10 cm limited to involved areas; Pouchitis - multiple biopsies from pouch and afferent loop documented; Acute graft-versus-host disease - flexible sigmoidoscopy: 4+ biopsies from rectum/sigmoid and 4+ from left colon; Ileocolonoscopy: 4+ biopsies from terminal ileum, ascending, transverse, descending colon, and rectum/sigmoid.

Key Coverage Criteria

Colonoscopy (considered medically necessary every 10 years for persons at average risk);
Specific biopsy procedural/collection requirements (covered when medically necessary):
Inflammatory bowel disease, diagnosis - 2 or more biopsies from 5 different locations, including the ileum and rectum;
The USPSTF recommended screening for CRC in all adults aged 50 to 75 years (A recommendation).
Constipation (K59.00 - K59.09)
Noninfective enteritis and colitis (K51.00 - K55.9)

8 Active Policies

ANTHEM-CG-MED-35, Retinal Telescreening Systems

ANTHEM-CG-LAB-28, Prostate Specific Antigen Testing

ANTHEM-LAB.00051, Per- and Polyfluoroalkyl Substances (PFAS) Testing

CIGNA-A004, Preventive Care Services

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0516, Colonoscopy, Colorectal Cancer Screening, and Related Procedures

AETNA-CPB-0535, Virtual Gastrointestinal Endoscopy

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

`Z00.01`, Encounter for general adult medical examination with abnormal findings

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

Z00.01, Encounter for general adult medical examination with abnormal findings

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`Z00.01`, Encounter for general adult medical examination with abnormal findings