Does Z98.85 require prior authorization?

No, Z98.85 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z98.85`, Transplanted organ removal status

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Services must be submitted/billed with the most appropriate CPT/HCPCS and an eligible covered ICD-10-CM diagnosis code from Table 1; claims without covered diagnosis codes will be denied.
For requests/exceptions for more than two TTEs within a rolling 12 months, the claim must be billed with a covered diagnosis from Table 1 and a diagnosis from Table 2 that supports the increased frequency.
Myocardial strain imaging (CPT 93356) requires documentation that the primary TTE (CPT 93303/93304/93306/93307/93308) on the same date of service is medically necessary AND documentation showing either (a) exposure to medications/radiation that could cause cardiotoxicity (timing 'prior to, during or following' exposure) OR (b) evaluation of hypertrophic cardiomyopathy.
General administrative requirement: reimbursement only provided if service is submitted in accordance with the relevant criteria in the Coverage Policy (including covered diagnosis and/or procedure codes) and the terms of the applicable benefit plan document.

Key Coverage Criteria

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 [...]
Non-stress TTE (with or without 3D; with contrast as needed) is considered medically necessary for the following specific clinical scenarios: Multisystem Inflammatory Syndrome (MIS) associated with SARS-CoV-2 (COVID-19) infection; individual taking FINTEPLA® (fenfluramine) for an FDA-approved indication (e.g., Dravet syndrome); individual taking CAMZYOS™ (mavacamten) for an FDA-approved indication (i.e., adult with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy [oHCM]).
A transthoracic echocardiogram may be considered medically necessary when criteria in the applicable policy statements are met and when billed with a diagnosis code from Table 1 (Covered ICD-10-CM Diagnosis codes).
More than two transthoracic echocardiograms submitted within a rolling twelve months may be considered medically necessary when criteria are met and when billed with a covered diagnosis code from Table 1 and a diagnosis from Table 2 (diagnoses with frequency allowances).
Myocardial strain imaging (CPT 93356) is considered medically necessary when the primary TTE (CPT 93303, 93304, 93306, 93307, 93308) on the same date of service is medically necessary AND either (a) prior to, during or following exposure to medications/radiation that could result in cardiotoxicity, or (b) to evaluate hypertrophic cardiomyopathy.

1 Active Policy

CIGNA-0510, Transthoracic Echocardiography in Adults

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Z98.85, Transplanted organ removal status