Does Z86.005 require prior authorization?

No, Z86.005 does not require prior authorization (high confidence). Code is covered without prior authorization.

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`Z86.005`, Personal history of in-situ neoplasm of middle ear and respiratory system

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is 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.
Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.

Key Coverage Criteria

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 [...]
Non-stress TTE (with or without 3D; with contrast as needed) is considered medically necessary for the following specific clinical scenarios: Multisystem Inflammatory Syndrome (MIS) associated with SARS-CoV-2 (COVID-19) infection; individual taking FINTEPLA® (fenfluramine) for an FDA-approved indication (e.g., Dravet syndrome); individual taking CAMZYOS™ (mavacamten) for an FDA-approved indication (i.e., adult with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy [oHCM]).
A transthoracic echocardiogram may be considered medically necessary when criteria in the applicable policy statements are met and when billed with a diagnosis code from Table 1 (Covered ICD-10-CM Diagnosis codes).

`Z86.005`, Personal history of in-situ neoplasm of middle ear and respiratory system

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

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Z86.005, Personal history of in-situ neoplasm of middle ear and respiratory system

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`Z86.005`, Personal history of in-situ neoplasm of middle ear and respiratory system