Does Z30.2 require prior authorization?

No, Z30.2 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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`Z30.2`, Encounter for sterilization

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

Medical records and pathology reports demonstrating disease or injury and documenting that the procedure's primary objective was treatment (not sterilization) are required to support coverage.
Claims lacking pathological evidence of necessity are subject to postpayment review and recoupment.
Legal/regulatory citations applicable to coverage determinations include Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k), which govern payment exclusions for procedures lacking medical necessity.
Medical record must include pathological evidence demonstrating that the sterilization procedure was necessary to treat an illness or injury.

Key Coverage Criteria

Sterilization procedures are covered when they are necessary to treat an illness or injury rather than performed solely to cause permanent infertility.
Hysterectomy performed to remove a uterus because of a tumor is covered when the primary objective is treatment of the disease.
Bilateral oophorectomy (removal of diseased ovaries) is covered when performed to treat ovarian disease such as a tumor.
Bilateral orchiectomy is covered when performed as necessary treatment for prostate cancer or other testicular disease where removal is therapeutic.
Bilateral orchiectomy is covered when performed to treat conditions such as prostate cancer.
Sterilization is covered when performed as necessary treatment of an illness or injury and the primary objective is treatment rather than achieving sterilization.

5 Active Policies

A59060, Sterilization

CIGNA-0013, Endometrial Ablation

AETNA-CPB-0027, Vasectomy Procedures and Chronic Scrotal Content Pain

AETNA-CPB-0657, Tubal Sterilization

A53356, Sterilization

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Z30.2, Encounter for sterilization