E71.39 — Other disorders of fatty-acid metabolism
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- Documentation of infant age (≤ 12 months) when requesting coverage under the infant nutritional formula indication.
- Documentation that the formula is specifically formulated for the treatment of an inborn error of metabolism and medical necessity for that IEM.
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
3 Active Policies
CIGNA-0136 — Infant Nutritional Formula - (0136)
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
Related Codes
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