Does A04.72 require prior authorization?

No, A04.72 does not require prior authorization (high confidence). Code is covered without prior authorization.

`A04.72` — Enterocolitis due to Clostridium difficile, not specified as recurrent

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
Submit the appropriate CPT® or PLA code (or CPT® 87999 if no specific code) with each claim and ensure the CPT/HCPCS code describes the service performed.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
FDA-approved or cleared molecular infectious disease tests performed consistent with their intended use labeling are covered without a DEX Z-Code and Technical Assessment when billed with appropriate ICD-10-CM diagnosis codes and supporting documentation.
Expanded (>5 pathogens) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered if billed from place of service (POS) 19, 21, 22, or 23, or if ordered by an appropriate specialist depending on beneficiary immune status and the specialist is diagnosing/treating the beneficiary.

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

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A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

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L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

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L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

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