Does Z96.21 require prior authorization?

No, Z96.21 does not require prior authorization (high confidence). Covered without prior authorization.

`Z96.21`, Cochlear implant status

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The policy contains no explicit, dedicated 'Documentation Requirements' section.
Coverage is conditional on 'selection criteria' being met (policy repeatedly states 'CPT codes covered if selection criteria are met' and 'ICD-10 codes covered if selection criteria are met'), therefore documentation must demonstrate that applicable selection criteria are met (selection criteria are not detailed in this document).
Implied documentation to support coverage (inferred from policy content): documentation of hearing impairment diagnosis (relevant ICD-10 code), documentation of cochlear implant placement/status (e.g., Z96.21), clinical justification for aural rehabilitation (e.g., pre/post-implant audiologic evaluations, evaluation of auditory rehabilitation status [CPT 92626], and evidence the patient has not reached a plateau in performance if a cochlear implant user).

Aetna considers aural rehabilitation (including auditory verbal therapy [AVT]) medically necessary as speech therapy for members with hearing impairments and after placement of a cochlear implant.
Auditory rehabilitation for members with cochlear implants (i.e., services after placement of a cochlear implant).
Auditory rehabilitation services described by CPT codes when selection criteria are met: 92626 (Evaluation of auditory rehabilitation status; first hour), 92627 (each additional 15 minutes), 92630 (Auditory rehabilitation; pre-lingual hearing loss), 92633 (Auditory rehabilitation; post-lingual hearing loss).
Related services/care in conjunction with cochlear device implantation (CPT 69930) and cochlear device/system/supplies (HCPCS L8614-L8624) when selection criteria are met.
Covered ICD-10 diagnoses (when selection criteria are met): H74.01-H74.93 (Other disorders of middle ear/mastoid), H80.00-H80.93 (Otosclerosis), H81.01-H81.09 (Meniere's disease), H90.0-H90.8 (Conductive and sensorineural hearing loss), H93.011-H93.099 and H93.211-H93.93 (Other disorders of ear, not elsewhere classified), and Z96.21 (Cochlear implant status).
Auditory verbal therapy (AVT) is included where indicated above (policy explicitly references AVT as included in 'aural rehabilitation').

AETNA-CPB-0034, Aural Rehabilitation

AETNA-CPB-0243, Speech Therapy

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