Does Z86.012 require prior authorization?

No, Z86.012 does not require prior authorization (high confidence). Covered without prior authorization.

`Z86.012`, Personal history of benign carcinoid tumor

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
Document imaging reports (e.g., barium enema, CT, or other imaging) showing the abnormality prompting colonoscopy.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Colonoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect or stricture).
Colonoscopy is covered for evaluation of unexplained gastrointestinal bleeding presenting as hematochezia not thought to be from a rectal or perianal source.
Colonoscopy is covered for melena of unknown origin after an upper GI source has been excluded.

WPS-J5-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

A56394, Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

WPS-J8-L34614, Colonoscopy and Sigmoidoscopy-Diagnostic

Ask Backwork about documentation requirements, denial risks, or coverage in your state.