Does Z13.31 require prior authorization?

No, Z13.31 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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`Z13.31`, Encounter for screening for depression

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

Quantitative EEG must be performed only as an adjunct to a traditional EEG (policy phrase: "medically necessary only as an adjunct to traditional EEG")
Use must match one of the medically necessary purposes listed (ambulatory recording to facilitate subsequent expert visual EEG interpretation; continuous EEG monitoring by frequency-trending in OR/ICU; evaluation when neuroimaging and routine EEG are inconclusive for cerebrovascular disease; evaluation of dementia/encephalopathy when diagnosis unresolved after initial clinical evaluation; screening for possible epileptic seizures in high-risk ICU members; screening for spikes/seizures during long-term EEG monitoring; topographic voltage and dipole analysis in pre-surgical evaluations for intractable epilepsy)
Claims for CPT codes 95961 and +95962 and HCPCS S8040 require that the applicable selection criteria be met (policy repeatedly notes "covered if selection criteria are met")

Key Coverage Criteria

ICD-10 codes covered if selection criteria are met (not all-inclusive): F02.80: Dementia in other diseases classified elsewhere, without behavioral disturbance
ICD-10 codes covered if selection criteria are met (not all-inclusive): F02.A0, F02.B0, F02.C0, F02.C4: Dementia in other diseases classified elsewhere, with behavioral disturbance
ICD-10 codes covered if selection criteria are met (not all-inclusive): F03.90 - F03.C4: Unspecified dementia
ICD-10 codes covered if selection criteria are met (not all-inclusive): F06.1, F06.8: Psychotic disorders with hallucinations and other specified mental disorders due to known physiological conditions
ICD-10 codes covered if selection criteria are met (not all-inclusive): G40.00 - G40.919: Epilepsy and recurrent seizures
ICD-10 codes covered if selection criteria are met (not all-inclusive): G92.00 - G92.9: Toxic encephalopathy

2 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0221, Quantitative EEG (Brain Mapping)

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Z13.31, Encounter for screening for depression