Does 86258 require prior authorization?

No, 86258 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 86258?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`86258`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation of symptoms suggestive of celiac disease when serologic testing is performed (for use as preliminary diagnostic test).
When monitoring response to a gluten-free diet, documentation of prior diagnosis and gluten-free diet initiation and serial serologic results.
Documentation of first-degree relative status when screening relatives of affected individuals (family history, relationship).
Documentation of type 1 diabetes diagnosis when screening persons with T1DM for celiac disease.

Key Coverage Criteria

Persons with discrepant celiac-specific serology and histology;
Serological testing of IgA anti-human tissue transglutaminase (TTG) antibodies, IgG and IgA deamidated gliadin antibodies (DGP), and IgA anti-endomysial antibodies (EMA) for any of the following indications:
As a preliminary diagnostic test for persons with symptoms suggestive of celiac disease;
To monitor response to a gluten-free diet;
To screen first-degree relatives of individuals with celiac disease;
To screen persons with type 1 diabetes for celiac disease.

1 Active Policy

AETNA-CPB-0561 — Celiac Disease Laboratory Testing

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

For HLA-DQ2/DQ8 genotyping, documentation to support one of the listed indications: seronegative persons with equivocal small bowel histology (Marsh I-II) (include biopsy/histology report); evaluation of persons on a gluten-free diet in whom no serologic testing was performed before starting the diet (document GFD start and lack of prior serology); discrepant celiac-specific serology and histology (include serology and histology reports); suspicion of refractory celiac disease where the original diagnosis remains in question (provide prior diagnostic documentation); or Down syndrome (document diagnosis).

86258