Does Z68.53 require prior authorization?

No, Z68.53 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z68.53`, Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Documentation of the diagnosis/indication prompting nutritional counseling (e.g., obesity, overweight with documented BMI and specified CVD risk factors, diabetes mellitus, eating disorder, gastrointestinal disorder, hypertension, kidney disease, seizures, COPD, ESRD).
Documentation of BMI or appropriate BMI/BMI-for-age percentiles (adult BMI values and pediatric percentiles) when used to support coverage (Z68.* codes referenced).
Documentation of presence of cardiovascular disease risk factors when invoking coverage for overweight adults (explicitly: hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome).

For ESRD-related services: documentation that services included monitoring for adequacy of nutrition, assessment of growth and development, counseling of parents (for pediatric patients), and documentation of the number of face-to-face physician visits per month as required by the specific CPT code descriptor.

For G0270/G0271: documentation that the visit is a reassessment/subsequent intervention following a second referral in the same year for change in diagnosis, medical condition, or treatment regimen (including justification for additional hours for renal disease).

For diabetes outpatient self-management training (G0108/G0109) and medical nutrition therapy (CPT 97802/97803/97804): documentation of session content, individual vs group format, duration (per 15 or 30 minute increments as appropriate), and that criteria for coverage are met.

Key Coverage Criteria

Medical nutrition therapy/nutritional counseling for chronic disease states: kidney disease.
Nutritional counseling as a medically necessary preventive service for children who are obese.
Nutritional counseling as a medically necessary preventive service for adults who are obese.
Nutritional counseling for adults who are overweight (BMI > 25.0 kg/m2) and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome).
Medical nutrition therapy/nutritional counseling for chronic disease states where dietary adjustment has a therapeutic role (examples explicitly listed): diabetes mellitus.
Medical nutrition therapy/nutritional counseling for chronic disease states: eating disorders.

6 Active Policies

ANTHEM-CG-LAB-29, Gamma Glutamyl Transferase Testing

ANTHEM-CG-LAB-25, Outpatient Glycated Hemoglobin and Protein Testing

ANTHEM-CG-LAB-30, Outpatient Laboratory-based Blood Glucose Testing

AMBETTER-CP.MP.157, 25-hydroxyvitamin D Testing in Children and Adolescents

AMBETTER-CP.MP.154, Thyroid Hormones and Insulin Testing in Pediatrics

AETNA-CPB-0049, Nutritional Counseling

`Z68.53`, Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

Z68.53, Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`Z68.53`, Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age