Does Z92.83 require prior authorization?

Yes, Z92.83 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

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`Z92.83`, Personal history of failed moderate sedation

ICD-10-CM

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Documentation Required

All documentation supporting MAC must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
When G9 modifier is used for history of severe cardiopulmonary disease, document the clinical decision-making process and the need for additional monitoring in the medical record.

Key Coverage Criteria

Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
Moderate sedation (age 18 or over) is medically necessary when the interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (examples: sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).
Moderate sedation (age 18 or over) is medically necessary when BOTH of the following are met: (a) the procedure being performed is ANY of: epidural steroid injection, epidural blood patch, facet joint injection, peripheral and/or spinal nerve root block, sacroiliac joint injection; AND (b) severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, or other severe psychiatric condition(s), or severe cognitive impairment(s) that would risk endangering the [...]

4 Active Policies

NOVITAS-JH-L35049, Monitored Anesthesia Care

NOVITAS-JL-L35049, Monitored Anesthesia Care

A57361, Billing and Coding: Monitored Anesthesia Care

CIGNA-0551, Anesthesia Services for Interventional Pain Management Procedures in an Adult

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Z92.83, Personal history of failed moderate sedation