Does Z12.5 require prior authorization?

No, Z12.5 does not require prior authorization (high confidence). Covered without prior authorization.

`Z12.5`, Encounter for screening for malignant neoplasm of prostate

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Document member age and risk status (e.g., average-risk versus high-risk; high-risk examples cited: African-American race and family history of prostate cancer) to support preventive PSA screening eligibility (policy states preventive screening ages: 45+ average-risk; 40+ high-risk).
Document signs or symptoms of prostate cancer when performing PSA testing for diagnostic purposes (policy: "PSA testing for men of all ages with signs or symptoms of prostate cancer").
Document prior elevated PSA results when performing annual PSA screening for routine follow-up (policy: "Annual PSA screening when used for routine screening in men with previously elevated PSAs or signs or symptoms of disease.")
Document follow-up intent when PSA testing is performed for monitoring men with known prostate cancer (policy: "for follow-up of men with prostate cancer").

ICD-10 codes listed as covered if selection criteria are met: C61; D07.5; D29.1; D40.0; N40.0 - N40.3; N42.30 - N42.39; R97.20 - R97.21; Z12.5; Z15.03; Z80.42; Z85.46.
PSA testing for men of all ages with signs or symptoms of prostate cancer.
Annual PSA screening when used for routine screening in men with previously elevated PSAs or signs or symptoms of disease.
Prostate-specific antigen (PSA) screening as a preventive service for men 45 years of age and older who are considered average-risk for prostate cancer.
Prostate-specific antigen (PSA) screening as a preventive service for men 40 years of age and older who are considered at high-risk for prostate cancer. Risk groups include African-American men and men with a family history of prostate cancer.
PSA testing for follow-up of men with prostate cancer.

AMBETTER-CG-Onc-Algo-2025.1, Concert Genetic Oncology: Algorithmic Testing

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

AETNA-CPB-0001, Transrectal Ultrasound

AETNA-CPB-0521, Prostate Cancer Screening

AETNA-CPB-0698, Prostate Biopsy

Ask Backwork about documentation requirements, denial risks, or coverage in your state.