Does Z98.52 require prior authorization?

No, Z98.52 does not require prior authorization (high confidence). Covered without prior authorization.

`Z98.52`, Vasectomy status

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Clinical records supporting the diagnosis of post-vasectomy pain syndrome (history, pain duration, prior treatments, response to spermatic cord block if performed) — inferred from the policy statements describing required failed therapies and typical workup prior to surgery.
Documentation that the member has failed non-steroidal anti-inflammatory medications and local nerve blocks/steroid injections (per Medical Necessity statement).
Documentation that "selection criteria are met" for covered vasectomy reversal procedures (CPT 55400) and for epididymectomy (CPT 54860, 54861) when those CPTs are billed (policy notes these CPTs are "covered if selection criteria are met").
Use of ICD-10 code G89.28 (Other chronic postprocedural pain [post-vasectomy]) when applicable to indicate covered diagnosis.

Stopping other contraception: "Patients may stop using other methods of contraception when 1 un-centrifuged fresh semen specimen shows azoospermia or less than or equal to 100,000 non-motile sperm/ml." (policy background guidance)
Aetna considers vasectomy reversal medically necessary for the treatment of post-vasectomy pain syndrome if member has failed non-steroidal anti-inflammatory medications and local nerve blocks/steroid injections.
Vasectomy reversal procedures (CPT 55400) — covered if selection criteria are met.
Epididymectomy (CPT 54860 unilateral; 54861 bilateral) — covered if selection criteria are met.
ICD-10 code G89.28 (Other chronic postprocedural pain [post-vasectomy]) — listed as an ICD-10 code covered if selection criteria are met.
N98.1: Hyperstimulation of ovaries

AETNA-CPB-0027, Vasectomy Procedures and Chronic Scrotal Content Pain

AETNA-CPB-0327, Infertility

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