Does Z01.20 require prior authorization?

No, Z01.20 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z01.20`, Encounter for dental examination and cleaning without abnormal findings

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Laboratory tests are not covered unless they are ordered by a physician or other qualified health professional. Please check benefit plan descriptions.
For use of late-night salivary cortisol in diagnosing Cushing's syndrome: exclude exogenous glucocorticoid use and perform testing in patients with multiple and progressive features compatible with the syndrome and patients with adrenal incidentaloma (per Endocrine Society guideline text in policy).
No explicit Medicare documentation or billing requirements are specified in the provided text.

If screening tests (e.g., late-night salivary cortisol or urine cortisol) are positive, a confirmatory second test is recommended and patients should be referred to an endocrinologist (per Endocrine Society guideline text in policy).

CPT codes for salivary testing are 'covered if selection criteria are met' — clinical documentation demonstrating that selection/coverage criteria are met must be present (selection criteria not detailed in this excerpt).

When applied as diagnostic/screening tests (e.g., for cancers, OLP, periodontal disease, CKD, TBI, GERD/LPR, celiac disease, etc.), supporting evidence (diagnostic test comparisons, sensitivity/specificity, correlation with gold-standard) is required; the policy lists these salivary tests as experimental/investigational due to insufficient evidence (implying documentation of validated indication would be required to justify coverage).

Key Coverage Criteria

Use of the CDOT salivary test in settings such as dentist offices, primary care centers and specialized cancer clinics to aid early detection (as suggested by the authors)
The test was validated in former and current smokers and in younger and older participants (study populations in which the model was evaluated)
Late night salivary cortisol for diagnosing Cushing's syndrome.
ICD-10 covered diagnosis for this indication: E24.0 - E24.9 (Cushing's syndrome).
Use of salivary lactate dehydrogenase (SaLDH) as a potential biomarker for screening, early detection, and follow-up of oral potentially malignant disorders (OPMD) and head and neck cancer (HNC).
Use of salivary biomarkers (including SaLDH and other salivary molecular markers) for detection/diagnosis of oral cancer and head & neck cancers (general statement supported by systematic reviews/meta-analyses).

`Z01.20`, Encounter for dental examination and cleaning without abnormal findings

Prior Authorization

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

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Z01.20, Encounter for dental examination and cleaning without abnormal findings

Prior Authorization

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`Z01.20`, Encounter for dental examination and cleaning without abnormal findings