Does Z00.6 require prior authorization?

No, Z00.6 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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`Z00.6`, Encounter for examination for normal comparison and control in clinical research program

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

Claims for investigational chemotherapy drugs administered in outpatient clinical trials must include condition code 30, modifier Q0, and diagnosis code Z00.6 on the Medicare claim.
Billing and coverage must follow CMS guidance for qualifying clinical trials (CMS IOM Pub 100-04, Medicare Claims Processing Manual, Ch.32 §69.5 and CMS IOM Pub 100-03, NCD Manual, Ch.1 Pt.4 §310.1).
Providers should document that the drug use is investigational and that the trial is qualifying per CMS definitions when submitting claims or when retaining records (follow CMS manual requirements).

Key Coverage Criteria

Medicare covers routine costs of qualifying clinical trials as described in CMS guidance.
Medicare covers reasonable and necessary items and services used to diagnose and treat complications arising from participation in any clinical trial.
Personal history of sustained ventricular tachycardia (spontaneous or EP-induced) not associated with an acute myocardial infarction and not due to a transient or reversible cause is an indication for ICD implantation.
Personal history of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause is an indication for ICD implantation.
Patients with prior myocardial infarction and measured left ventricular ejection fraction (LVEF) ≤ 0.30 are indicated for ICD implantation provided they do not have NYHA class IV heart failure, have not had CABG/PCI in the past 3 months, have not had an MI within the past 40 days, and are not candidates for coronary revascularization.
Patients with severe ischemic dilated cardiomyopathy, no prior sustained VT or VF arrest, NYHA class II or III heart failure, and LVEF ≤ 35% are indicated for ICD implantation provided they have not had CABG/PCI within 3 months, have not had MI within 40 days, and are not candidates for coronary revascularization.

5 Active Policies

A56391, Billing and Coding: Implantable Automatic Defibrillators

CIGNA-A003, Clinical Trials – (A003)

UHC-POL-clinical-trials, Clinical Trials

A53784, Billing and Coding: The Routine Costs of Investigational Chemotherapy Drugs Studied In a Qualifying Clinical Trial

A59892, Billing and Coding: MolDX: Category B IDE Studies

`Z00.6`, Encounter for examination for normal comparison and control in clinical research program

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

Z00.6, Encounter for examination for normal comparison and control in clinical research program

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`Z00.6`, Encounter for examination for normal comparison and control in clinical research program