Does Z13.41 require prior authorization?

No, Z13.41 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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`Z13.41`, Encounter for autism screening

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

Documentation that developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified to justify ASD evaluation and diagnosis.
Evidence that the evaluation was performed by an appropriate certified/licensed health care professional (e.g., board certified behavioral analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, speech-language pathologist, audiologist).
Use of standardized parent interviews and direct, structured behavioral observation as part of diagnostic assessment; documentation of instruments used when applicable (e.g., Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule-2 (ADOS-2), Childhood Autism Rating Scale-2 (CARS-2), Asperger Syndrome Diagnostic Scale).

Key Coverage Criteria

Comparative genomic hybridization (CGH) when medical necessity criteria are met (see CPB 0787).
Complete medical evaluation including medical history and physical examination, including neurologic evaluation.
Parent and/or child interview (including siblings of children with autism).
Quantitative plasma amino acid assays to detect phenylketonuria.
Selective metabolic testing when the child exhibits any of the following: cyclic vomiting, recurrent vomiting and dehydration; early seizure; lethargy; hearing impairment; hypotonia; visual impairment; unusual odor; dysmorphic or coarse features; evidence of mental retardation or mental retardation cannot be ruled out; or occurrence/adequacy of newborn screening for a birth defect is questionable.
Genetic counseling for parents of a child with autism.

2 Active Policies

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0648, Autism Spectrum Disorders

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Z13.41, Encounter for autism screening