Does Z36.0 require prior authorization?

No, Z36.0 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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`Z36.0`, Encounter for antenatal screening for chromosomal anomalies

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.

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.
ICD-10 codes covered if selection criteria are met: Q90.0 - Q99.9 (Chromosomal anomalies) and Z36.0 - Z36.4, Z36.82, Z36.89 - Z36.9, Z36.8A (Encounter for antenatal screening of mother).
Services coded to the listed CPT/HCPCS/ICD-10 codes when selection criteria (as described above and in the policy) are met. (Covered CPT codes include, when selection criteria met: 76813, 76814, 81509, 81510, 81511, 81512, 84704; covered ICD-10 codes include Q90.0–Q99.9 and Z36.0–Z36.4, Z36.82, Z36.89–Z36.9, Z36.8A.)

7 Active Policies

A56199, Billing and Coding: Molecular Pathology Procedures

ANTHEM-CG-LAB-27, Human Chorionic Gonadotropin Testing

ANTHEM-CG-LAB-26, Outpatient Alpha-Fetoprotein Testing

ANTHEM-RAD.00038, Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care

AMBETTER-CG-Prenatal-Cell-Free-DNA-2025.1, Concert Genetic Testing: Prenatal Cell-Free DNA Testing

AETNA-CPB-0282, Noninvasive Down Syndrome Screening

ANTHEM-CG-RAD-26, Maternity Ultrasound in the Outpatient Setting

`Z36.0`, Encounter for antenatal screening for chromosomal anomalies

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

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Z36.0, Encounter for antenatal screening for chromosomal anomalies

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`Z36.0`, Encounter for antenatal screening for chromosomal anomalies