Does Z31.5 require prior authorization?

No, Z31.5 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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`Z31.5`, Encounter for procreative genetic counseling

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.

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.
H1299R Factor V (FV) variant (rs1800595): pooled analysis showed the variant was “slightly associated with RPL albeit without significance … demonstrated that there is no clear association between the FV H1299R variant and RPL.” (Capra et al, 2022) — indicating limited/uncertain utility of testing.
Maternal ApoE genotyping: “ε4 allele was found to confer an increased risk of RPL compared to the ε3 allele … Subgroup analysis ... revealed that these associations were restricted to the Asian population.” (Cargnin et al, 2023) — suggesting possible relevance of ApoE genotyping in Asian women.

2 Active Policies

A56199, Billing and Coding: Molecular Pathology Procedures

AETNA-CPB-0348, Recurrent Pregnancy Loss

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Z31.5, Encounter for procreative genetic counseling