Does Z31.440 require prior authorization?

No, Z31.440 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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`Z31.440`, Encounter of male for testing for genetic disease carrier status for procreative management

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

The medical record must document that the testing is expected to influence treatment of the condition for which the test is ordered and include an ordering physician/NPP requisition containing the relevant ICD-10-CM diagnosis code.
Ordering physician/NPP documentation should include history and physical or exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging) that support medical necessity.
Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.

For laboratory-developed tests (LDTs)/protocols, documentation must include the diagnostic test/assay, lab/manufacturer, comparable assays (if relevant), assay description, analytical validity, clinical validity, and clinical utility.

When CPT 81479 (unlisted molecular pathology procedure) is used, documentation must clearly identify the unique molecular pathology procedure performed and link that procedure to the billed code.

When multiple procedure codes (unique and/or unlisted) are submitted on a claim, the documentation supporting each code must be easily identifiable and linkable to the billed codes.

Key Coverage Criteria

When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.
Use modifier 91 only when a test is performed more than once on the same day for the same patient and the repeat testing is necessary to obtain multiple results in the course of treatment.
Preconception or prenatal carrier testing for an individual who has the capacity and intention to reproduce is considered medically necessary when ANY of the following criteria is met:
There is an identified pathogenic or likely pathogenic variant in a blood relative

2 Active Policies

A56199, Billing and Coding: Molecular Pathology Procedures

CIGNA-0514, Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis

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Z31.440, Encounter of male for testing for genetic disease carrier status for procreative management