Does E78.011 require prior authorization?

No, E78.011 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E78.011` — Heterozygous familial hypercholesterolemia [HeFH]

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The submitted medical record must support the selected ICD-10-CM code(s), and the submitted CPT/HCPCS code must accurately describe the service performed.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
When billing CPT 84999 for the listed tests, include a note identifying the specific test in the Remarks (Part A) or Narrative (Part B) area of the claim.
All documentation must be maintained in the patient's medical record, be legible, include patient identification (e.g., complete name) and dates of service, and be made available to the contractor upon request.

For tests that currently lack specific CPT codes (functional intracellular analysis and total antioxidant function), bill using CPT 84999 and add a note identifying which test was performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Coverage and reasonable/necessary determinations for assays for vitamins and metabolic function are governed by LCD L34914 and claims must meet that LCD's requirements to be covered.
Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
For covered laparoscopic restrictive procedures that require port replacement, bill CPT code 43771, 43772, or 43773.

A57559 — Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment

J05

L36523 — MolDX: Biomarkers in Cardiovascular Risk Assessment

J05

L39995 — Pharmacogenomic Testing

J06

A59915 — Billing and Coding: Pharmacogenomic Testing

J06

A57145

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