Does Z12.13 require prior authorization?

No, Z12.13 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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`Z12.13`, Encounter for screening for malignant neoplasm of small intestine

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 must demonstrate that selection criteria are met for covered CPT codes (e.g., 91065 and 95012) — supporting clinical records, history, and relevant prior conservative treatment (such as the 2-week lactose‑free diet for HBT)
When a test is billed, the medical record should support the specific covered indication listed in the policy (e.g., lactose intolerance symptoms after dietary trial, or asthma evaluation/monitoring) and include relevant clinical notes, prior treatment documentation, diagnosis codes, and age where applicable

For studies of OSA biomarkers: OSA diagnosis confirmed with a full overnight or home-based PSG (polysomnography) was required in retained studies (Canto Gde et al 2015).

For HBT: documentation of a trial of a lactose-free diet for 2 weeks and persistence of symptoms after that trial (to justify HBT per medical necessity criteria)

For FeNO: documentation of asthma diagnosis (ICD-10 J45.xx) and clinical indication for evaluation or for monitoring response to long-term control therapy; member must be aged 5 years or older for monitoring indication

Gastric emptying breath testing (GEBT): performed after an overnight fast; baseline breath tests are conducted and the patient ingests a specially made protein test meal enriched with carbon-13; breath samples measured at multiple time points over a 4-hour period.

Key Coverage Criteria

Measurement of exhaled nitric oxide (FeNO) for evaluation of asthma
Hydrogen breath testing (HBT) for evaluation of suspected lactose intolerance/deficiency after a 2-week trial of a lactose-free diet and symptoms of lactose intolerance persist
Measurement of exhaled nitric oxide (FeNO) for monitoring response to long-term control therapy in members aged 5 years and older
CPT 91065 (Breath hydrogen or methane test) covered when selection criteria are met
CPT 95012 (Nitric oxide expired gas determination) covered when selection criteria are met
ICD-10 diagnoses listed as covered when selection criteria are met: E73.0–E73.9 (lactose intolerance)

4 Active Policies

CIGNA-A004, Preventive Care Services

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0535, Virtual Gastrointestinal Endoscopy

AETNA-CPB-0691, Exhaled Breath Tests

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Z12.13, Encounter for screening for malignant neoplasm of small intestine