B95.2 — Enterococcus as the cause of diseases classified elsewhere
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- For reduction mammoplasty, the medical record must include height and weight of the beneficiary.
Key Coverage Criteria
- 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.
- Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
- Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.
- ICD-10-CM Codes that Support Medical Necessity — Dermabrasion (CPT Codes 15780-15783): L71.0; L71.1; L71.8; T20.311A; T20.311D; T20.311S; T20.312A; T20.312D; T20.312S; T20.32XA; T20.32XD; T20.32XS; T20.33XA; T20.33XD; T20.33XS; T20.34XA; T20.34XD; T20.34XS; T20.35XA; T20.35XD; T20.35XS; T20.36XA; T20.36XD; T20.36XS; T20.37XA; T20.37XD; T20.37XS; T20.39XA; T20.39XD; T20.39XS; T20.711A; T20.711D; T20.711S; T20.712A; T20.712D; T20.712S; T20.72XA; T20.72XD; T20.72XS; T20.73XA; T20.73XD; T20.73XS; T2 [...]
6 Active Policies
A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J05
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
J05
A57222 — Billing and Coding: Plastic Surgery
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
A57221 — Billing and Coding: Plastic Surgery
Related Codes
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