E80.4 — Gilbert syndrome
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Relevant laboratory data used to calculate serum biomarker panels (as applicable) and dates of labs.
- No additional explicit documentation requirements (e.g., required prior labs, imaging, or clinical notes) are specified in this document excerpt.
- Documentation of the clinical diagnosis that justifies the test (e.g., chronic hepatitis C or B, NASH/NAFLD, hereditary hemochromatosis, primary sclerosing cholangitis, other chronic liver disease) — ICD code(s) should support the indication.
- Clinical rationale/indication statement in the medical record specifying the intended purpose (e.g., distinguishing cirrhosis vs non‑cirrhosis, follow‑up of PSC, detection/prognosis of fibrosis in NASH).
Key Coverage Criteria
- Noninvasive prognostic assessment (risk stratification) in chronic liver disease
- Assessment of advanced fibrosis/portal hypertension and as adjunct in evaluating esophageal varices or portal hypertension
- Use of transient elastography (FibroScan) to measure liver stiffness for staging fibrosis and tracking changes during HCV treatment
- Use of serum biomarker panels (e.g., FibroTest/FibroSure, ActiTest, Hepascore, APRI, FIB-4, hyaluronic acid, hyaluronate-related models) for prediction of fibrosis/cirrhosis
- Pediatric assessment of liver stiffness and fibrosis where feasibility and correlation with other tests are demonstrated
- Use of quantitative multiparametric MRI (e.g., LiverMultiScan, multiparametric hepatic MRI) for quantitation of liver disease components (fibrosis, steatosis, inflammation) and aiding NASH diagnosis
3 Active Policies
AMBETTER-CG-Pharmacogenetics-2025.1-Version-B — Concert Genetic Testing: Pharmacogenetics (Version B)
A57802 — Billing and Coding: Hepatic (Liver) Function Panel
AETNA-CPB-0690 — Noninvasive Tests for Hepatic Fibrosis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.