Does Z86.003 require prior authorization?

No, Z86.003 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z86.003`, Personal history of in-situ neoplasm of oral cavity, esophagus and stomach

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.
For high-risk post-surgical follow-up at 1 year (with continued 24-month screening eligibility), report HCPCS code G0105 as the appropriate screening/high-risk colonoscopy code.

Key Coverage Criteria

Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
Non-stress transthoracic echocardiography (TTE) in adults (age 18 and older) considered medically necessary when consistent with ACC Appropriate Use Criteria (AUC) 'Appropriate Care' category (scores 7-9) for: Multimodality Imaging in Cardiovascular Evaluation of Patients Undergoing Nonemergent, Noncardiac Surgery (ACC/Doherty, et al., 2024); Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease (Sachdeva, et al., 2020); Multimodality Imaging in the Assessment [...]
Non-stress TTE considered medically necessary when consistent with ACC/AHA Guidelines (Class I and/or IIa) including: Guideline for the Diagnosis and Management of Hypertrophic Cardiomyopathy (Ommen, et al., 2024); Guideline for the Diagnosis and Management of Atrial Fibrillation (Joglar, et al., 2023); Guideline for the Diagnosis and Management of Aortic Disease (2022); Guideline for the Management of Heart Failure (Heidenreich, et al., 2022); Guideline for the Evaluation and Diagnosis of Chest [...]

4 Active Policies

CIGNA-0510, Transthoracic Echocardiography in Adults

A56612, Billing and Coding: CT of the Head

A56632, Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

`Z86.003`, Personal history of in-situ neoplasm of oral cavity, esophagus and stomach

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

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Z86.003, Personal history of in-situ neoplasm of oral cavity, esophagus and stomach

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

`Z86.003`, Personal history of in-situ neoplasm of oral cavity, esophagus and stomach