Does Z99.12 require prior authorization?

No, Z99.12 does not require prior authorization (high confidence). Covered without prior authorization.

`Z99.12`, Encounter for respirator [ventilator] dependence during power failure

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Billing note: policy states 'There is no specific code for esophageal Doppler monitoring (EDM)', so documentation should support use and billing under appropriate, reportable codes as applicable.
The policy does not specify a separate detailed documentation requirements section.
Clinical documentation should demonstrate that the patient meets one of the covered indications (need for intra-operative fluid optimization or ventilated status in the intensive care unit) and, where applicable, document the applicable ICD-10 diagnosis codes (e.g., J95.850, Z99.11, Z99.12).
Because the policy states "ICD-10 codes covered if selection criteria are met," documentation must support that the required selection criteria (as applicable) are met; the bulletin does not list those selection criteria explicitly.

Aetna considers esophageal Doppler monitoring (EDM) medically necessary for monitoring of cardiac output in either of the following 2 groups: Persons with a need for intra-operative fluid optimization; or Ventilated persons in the intensive care unit.
Operative patients with an expected substantial blood loss or fluid compartment shifts requiring fluid replacement (per AHRQ summary: "in patients undergoing surgical procedures with an expected substantial blood loss or fluid compartment shifts requiring fluid replacement, the clinical evidence for EDM was strong...").
ICD-10 codes covered if selection criteria are met: J95.850 (Mechanical complication of respirator [ventilated persons in the intensive care unit]).
ICD-10 codes covered if selection criteria are met: Z99.11 - Z99.12 (Dependence on respirator [ventilated persons in the intensive care unit]).
CMS determination (cited by the policy): coverage for EDM of cardiac output for ventilated patients in the ICU and operative patients with a need for intra-operative fluid optimization.

AETNA-CPB-0793, Esophageal Doppler Monitoring

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