Does Z36.9 require prior authorization?

No, Z36.9 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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`Z36.9`, Encounter for antenatal screening, unspecified

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

Documentation of prior or concurrent microarray or NIPT/maternal cell-free DNA testing (to support limitation/exclusion when such testing already performed).
Evidence that NT measurements were performed in a setting with demonstrated ultrasound credentialing and ongoing quality monitoring (e.g., participation in NT credentialing programs such as NTQR or FMF-US).
Documentation of gestational age at time of testing (tests and NT measurements should be performed in the appropriate first-trimester window; the policy references 11–13 weeks gestation for combined first-trimester screening and notes NT measurement windows [e.g., 10–14 weeks or 11 weeks +1 day to 13 weeks +6 days in cited trials]).

Key Coverage Criteria

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.)
First-trimester nuchal translucency (NT) testing alone (without serum analyte screening) for multiple gestations.
First-trimester NT measurement combined with first-trimester serum analyte tests that include pregnancy-associated plasma protein A (PAPP-A) plus beta-human chorionic gonadotropin (hCG) (free beta hCG, total hCG, or hyperglycosylated hCG are considered interchangeable).
Integrated, sequential, or contingent screening that includes first-trimester triple test (NT, PAPP-A, and hCG) plus second-trimester quadruple test (maternal serum alpha-fetoprotein [MSAFP], unconjugated estriol [uE3], inhibin A, and hCG).
Second-trimester serum analyte screening (per CPB 0464 - Serum and Urine Marker Screening for Fetal Aneuploidy).

6 Active Policies

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

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

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

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

AETNA-CPB-0282, Noninvasive Down Syndrome Screening

AETNA-CPB-0464, Maternal Biomarker Screening for Fetal Conditions

`Z36.9`, Encounter for antenatal screening, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

Z36.9, Encounter for antenatal screening, unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`Z36.9`, Encounter for antenatal screening, unspecified