Does E78.019 require prior authorization?

No, E78.019 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E78.019` — Familial hypercholesterolemia, unspecified

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Document the medical necessity for the chosen test frequency in the medical record (preferably on the test report).
Document that any applicable physician supervision requirement is met (preferably on the test report).
Medical record must document a clinical diagnosis and the specific reason for the study to substantiate medical necessity.
Document the specific reason for performing a stress echocardiogram instead of only an electrical (ECG) stress test.

Stress testing (exercise or pharmacological, including stress echocardiography) is covered when the results will potentially affect the patient’s treatment plan.
An initial follow-up stress test may be indicated several months after myocardial infarction (MI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA) when clinically appropriate.
A second follow-up stress test may be indicated approximately one year after the first follow-up test following MI, CABG, or PTCA when clinically appropriate.
Patients with silent coronary disease (no reliable signs or symptoms) may require stress testing as often as annually when clinically indicated.
Patients who present with reliable symptoms or signs of coronary artery disease (e.g., angina pectoris) may require stress testing as dictated by symptoms but typically will not require annual testing.
ICD-10-CM Codes that Support Medical Necessity — Group 1: The following list of ICD-10-CM codes applies to cardiovascular stress testing CPT codes 93015, 93016, 93017, 93018, 93350, 93351 93352 and J0153.

L36523 — MolDX: Biomarkers in Cardiovascular Risk Assessment

J05

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

J05

L39995 — Pharmacogenomic Testing

J06

A59915 — Billing and Coding: Pharmacogenomic Testing

J06

A58812

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