Does 72126 require prior authorization?

No, 72126 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 72126?

Medicare facility rate: $11.03. Non-facility rate: $11.03. Work RVU: 1.19.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.19

Facility

$11.03

Non-Facility

$11.03

Claims must meet the reasonable and necessary documentation requirements specified in LCD L35391; refer to that LCD for required medical record elements and prior authorization rules.
Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
Documentation and supporting information must be available to Medicare upon request.

Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
A supervising physician for an IDTF must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, meet proficiency standards for tests supervised, and provide general supervision for no more than three IDTF sites.

L33693 — Peripheral Venous Ultrasound

J09

A56848 — Billing and Coding: Multiple Imaging in Oncology

J12

L35391 — Multiple Imaging in Oncology

J12

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

L35007 — Vestibular and Audiologic Function Studies

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