Does Z81.8 require prior authorization?

No, Z81.8 does not require prior authorization (high confidence). Covered without prior authorization.

`Z81.8`, Family history of other mental and behavioral disorders

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claim must be accompanied by an appropriate ICD-10-CM diagnosis code(s) that supports medical necessity (see codes listed in the policy table).
Clinical documentation demonstrating that test results will inform medication selection or dosing (e.g., relevant medication history, reason for testing) — specific required documents not listed in excerpt.
Claims must include an appropriate ICD-10-CM diagnosis code from the policy’s listed codes to justify testing.
Medical record documentation must support the clinical rationale for pharmacogenetic testing (i.e., documentation that test results will be used to guide medication selection or dosing).

Pharmacogenetic testing prior to drug initiation to identify germline variants that may alter drug response or increase risk of drug toxicity.
Pharmacogenetic testing during treatment to evaluate an adverse drug reaction or to assess therapeutic response and guide ongoing medication management.
Pharmacogenetic panel testing (examples: GeneSight, Genomind, Neuropharmagen, NeuroIDgenetix, Tempus nP, IDgenetix, PersonalisedRX, PGXPSYCH, Focused Pharm Panel) to inform psychotropic medication selection or management in patients with psychiatric disorders or related conditions.
Pharmacogenetic panel testing to guide medication selection or dosing for patients with oncologic, neurologic, cardiovascular, vascular, thrombotic, or gastrointestinal conditions when gene–drug interactions may affect therapy (see associated ICD-10-CM codes).
Single-gene pharmacogenetic testing (examples: BCHE, CYP2C9, CYP2C19) when the test result will directly inform drug therapy decisions or dosing for an individual patient.
CYP2D6 pharmacogenetic testing (e.g., Variant Analysis 81226 and related PLA/unique codes 0070U–0076U) when used to guide medication selection or dosing for a patient who has one of the ICD-10-CM diagnoses listed in the policy.

AMBETTER-CG-Pharmacogenetics-2025.1-Version-B, Concert Genetic Testing: Pharmacogenetics (Version B)

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