Does Z32.01 require prior authorization?

Yes, Z32.01 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

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`Z32.01`, Encounter for pregnancy test, result positive

ICD-10-CM

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation Required

Appropriate ICD-10 diagnosis codes to support elective (e.g., Z33.2, Z32.01) or therapeutic abortion (specific maternal or fetal condition codes) must be submitted with claims.
Documentation of the underlying maternal health condition or fetal disease when therapeutic abortion CPT/HCPCS codes are used (e.g., clinical notes, diagnoses such as cancer, cardiac disease, fetal genetic abnormality, evidence of fetal demise, rape/incest documentation where applicable).
For medication-induced abortion, documentation of associated services is expected per S0199 description: patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, and ultrasound to confirm completion of abortion.
Clinical records to document complications and medically necessary treatment when treating spontaneous abortion (missed, incomplete, infected/septic abortion) or post-abortion complications.

Key Coverage Criteria

Elective abortion: termination of pregnancy at the discretion of the woman for reasons other than maternal health or fetal disease. Elective abortion is reflected when ICD-10-CM code Z33.2 (Encounter for elective termination of pregnancy) is billed alone or with Z32.01 (Encounter for pregnancy test, result positive).
Therapeutic abortion: termination of pregnancy due to underlying conditions related to maternal health or fetal disease. Indications include (but are not limited to) cancer; cardiovascular, hematologic or pulmonary disease; congenital heart disease; diabetes mellitus; ectopic pregnancy; exposure to a teratogenic substance known to cause fetal malformation(s); fetal genetic abnormalities; fetal death prior to the age of viability; fetal structural defects (e.g., neural tube defects, cardiac abnor [...]
Medically necessary treatment of complications following an abortion (e.g., missed or incomplete abortion, infected/septic abortion) is covered.
Ectopic pregnancy (implanted outside the uterus) is covered and may require immediate surgical intervention as it constitutes a life-threatening condition.
Therapeutic abortion for treatment of a life‑threatening condition related to maternal health may be billed using the following CPT codes (may be used in combination with any diagnosis code[s]): 59100, 59120, 59121, 59130, 59136, 59140, 59150, 59151, 59812, 59820, 59821, 59830, 59870.
Induced abortion procedures that reflect therapeutic abortion when accompanied by diagnosis codes indicating underlying maternal/fetal conditions include CPT codes: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866.

2 Active Policies

CIGNA-A006, Abortion

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

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Z32.01, Encounter for pregnancy test, result positive