Does Z92.22 require prior authorization?

No, Z92.22 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z92.22`, Personal history of monoclonal drug therapy

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

If bone metastasis (C79.51 or C79.52) is treated, the medical record must also contain the diagnosis of the primary malignant neoplasm and be available on request.
Medical records must include diagnostic information and lab results that support medical necessity, including documentation of specific signs and symptoms substantiating FDA labeled or off‑label use.
The record should indicate the patient was advised to take adequate calcium and vitamin D supplementation.
Diagnosis codes supporting medical necessity must be submitted on the claim, including breast cancer code plus bone loss code and a code documenting current adjuvant SERM or aromatase inhibitor therapy when applicable.

Key Coverage Criteria

Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.
Bisphosphonate therapy is covered for bone metastasis (C79.51 or C79.52) provided the patient's record also contains a diagnosis of the primary malignant neoplasm.
In breast cancer patients receiving adjuvant selective estrogen receptor modulators or aromatase inhibitor therapy, bisphosphonates are covered when billed with an appropriate breast cancer diagnosis code and a bone loss diagnosis code documenting treatment indication.
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 [...]

5 Active Policies

WPS-J5-L34648, Bisphosphonate Drug Therapy

A56907, Billing and Coding: Bisphosphonate Drug Therapy

WPS-J8-L34648, Bisphosphonate Drug Therapy

CIGNA-0510, Transthoracic Echocardiography in Adults

A57189, Billing and Coding: Serum Magnesium

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Z92.22, Personal history of monoclonal drug therapy