Does Z13.858 require prior authorization?

No, Z13.858 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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`Z13.858`, Encounter for screening for other nervous system disorders

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

Discern / NeuroDiagnostics: peripheral skin samples are collected via a standard 2-3mm punch biopsy taken from the bicep/forearm area (procedure description/collection requirement).
MindX Blood Test - Memory/Alzheimer's: 'The test is available by prescription only.' (requires ordering provider prescription) and is 'indicated for middle aged or elderly patients presenting signs of forgetfulness, depression, periods of high stress, and a family history of dementia.'
Discern / NeuroDiagnostics (skin fibroblast assays): 'Patients tested must first have a clinical diagnosis of dementia (the duration of such dementia to extend from the first year of dementia forward). The intended population will range in age from 55-90 years old.'

General (implicit): many biomarker studies referenced required clinical characterization (e.g., clinical diagnosis of AD/MCI, neuropsychological testing, MMSE, Clinical Dementia Rating), APOE genotype status, imaging (MRI, PET), and CSF collection via lumbar puncture — meaning interpretation in research/clinical studies depends on paired clinical and imaging/CSF data.

Key Coverage Criteria

Lumbar puncture (CSF testing) to confirm presence of elevated phosphorylated tau (P-tau) and/or elevated total tau (T-tau) and reduced beta amyloid-42 (Aβ42) or a low Aβ42/Aβ40 ratio as determined by the lab assay detected in cerebrospinal fluid (CSF) for the assessment of mild cognitive impairment (MCI) when Alzheimer's disease (AD) is suspected.
Brain magnetic resonance imaging (MRI) for persons on aducanumab-avwa (Aduhelm) or lecanemab-irmb (Leqembi) therapy for the following indications: (a) within one year prior to initiating aducanumab or lecanemab therapy to indicate AD, or (b) to evaluate for evidence of amyloid-related imaging abnormalities (ARIA) prior to the 5th, 7th, 9th, and 12th aducanumab dose or prior to the 5th, 7th, and 14th lecanemab dose (see CPB 0996 and CPB 1026 for details).
Genetic mutation testing for APP, PSEN1, or PSEN2 for members with MCI or mild AD dementia who are less than 50 years of age and who are being considered for enrollment in a clinical trial of aducanumab (Aduhelm) or lecanemab (Leqembi).
Amyloid PET scan indications are referenced (see CPB 0071 - Positron Emission Tomography (PET)) — amyloid PET is handled under CPB 0071.
Alzheimer's disease (G30.0 - G30.9)
Neurology (mild cognitive impairment) — CSF B-amyloid 1-42 and 1-40 chemiluminescence enzyme immunoassay reported as positive/likely positive/negative (0358U) — covered if selection criteria are met

12 Active Policies

AMBETTER-CG-Epilepsy-Neurodegen-Neuromusc-DO-2025.1, Concert Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Conditions

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0071, Positron Emission Tomography (PET)

AETNA-CPB-0158, Neuropsychological and Psychological Testing

AETNA-CPB-0212, Musculoskeletal Assessment Systems

AETNA-CPB-0279, Magnetic Source Imaging/Magnetoencephalography

AETNA-CPB-0340, Antibody Tests for Neurologic Diseases

AETNA-CPB-0349, Alzheimer's Disease Tests

AETNA-CPB-0608, Salivary Tests

AETNA-CPB-0614, Huntington's Disease

AETNA-CPB-0663, Cerebral Perfusion Studies

AETNA-CPB-0703, Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow

`Z13.858`, Encounter for screening for other nervous system disorders

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

Z13.858, Encounter for screening for other nervous system disorders

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`Z13.858`, Encounter for screening for other nervous system disorders