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ICD-10-CM Z87.442, Personal history of urinary calculi | No Prior Auth

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`Z87.442`, Personal history of urinary calculi

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

ICD-10 R82.991 - R82.998 are listed as 'covered if selection criteria are met' — selection criteria are referenced but not detailed in the document.
The policy does not list explicit documentation requirements (e.g., required clinical notes, lab results, prior therapies) for metabolic/environmental profiling or for imaging; no other specific documentation elements are specified in the CPB.

Key Coverage Criteria

ICD-10 codes R82.991 - R82.998 (Other abnormal findings in urine) are listed as "ICD-10 codes covered if selection criteria are met" (selection criteria not specified in the CPB).
ICD-10 codes R82.991 - R82.998 (Other abnormal findings in urine) covered if selection criteria are met
Note: The policy does not state any metabolic or environmental profiling methods as covered for assessment of kidney stone risk; instead these are listed as experimental and investigational (see Limitations).

1 Active Policy

AETNA-CPB-0392, Kidney Stones: Selected Interventions

Related Codes

72192(1 policies)72193(1 policies)72194(1 policies)72195(1 policies)72196(1 policies)72197(1 policies)N20.0(1 policies)R82.991(1 policies)

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