Does Z87.51 require prior authorization?

No, Z87.51 does not require prior authorization (high confidence). Covered without prior authorization.

`Z87.51`, Personal history of pre-term labor

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation that the patient is symptomatic for preterm labor (i.e., presenting with signs/symptoms of preterm labor or threatened preterm labor).
Record of test type and result (e.g., fFN positive/negative; PAMG-1, pIGFBP-1, phIGFBP-1, PartoSure, qfFN quantitative values where applicable).
Documentation of laboratory turnaround time and that results were available quickly enough to impact immediate clinical management (policy specifies generally considered to be under 4 hours).
When tests are used to guide decisions (e.g., administration of antenatal steroids, hospitalization, transfer to higher-level care, use of tocolytics), clinical rationale and how the test result influenced the management decision should be documented.

ICD-10 diagnoses covered if selection criteria are met: O47.00 - O47.9 (False [threatened] labor).
ICD-10 diagnoses covered if selection criteria are met: O60.00 - O60.03 (Preterm labor without delivery).
ICD-10 diagnoses covered if selection criteria are met: Z87.51 (Personal history of pre-term labor).
Symptomatic pregnant women with suspected preterm labor when ALL of the following characteristics are present: Amniotic membranes intact; Cervical dilatation is minimal (less than 3 cm); Sampling is performed no earlier than 24 weeks, 0 days and no later than 34 weeks, 6 days of gestation.
Use of the fetal fibronectin (fFN) immunoassay to help assess risk of imminent preterm delivery (noting that a negative test has a maximal negative predictive value of approximately 96% for not delivering within the next 2 weeks).
Situations in which results are available quickly enough (generally considered to be under 4 hours) so that the results can assist in decisions concerning the immediate care of pregnant women (the policy states: “If the test is to be clinically useful, the results must be available from the laboratory in a timely manner (generally considered to be under 4 hours) so that the test can effect decisions concerning the immediate care of the patient.”).

AETNA-CPB-0166, Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Hormone Testing for Preterm Labor

AETNA-CPB-0348, Recurrent Pregnancy Loss

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