Does I49.5 require prior authorization?

No, I49.5 does not require prior authorization (high confidence). Code is covered without prior authorization.

`I49.5` — Sick sinus syndrome

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Bradycardia due to essential long-term drug therapy may be covered with Modifier -KX when no acceptable alternative exists; documentation of the drug therapy and lack of alternatives must be on file.
Objective diagnostic documentation (e.g., ECG/Holter/monitoring showing heart rate, asystole duration, pauses, electrophysiologic study results, tilt-table testing, and surgical notes) should be maintained to support attestation and coding.
Practitioners must attest with Modifier -KX that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression requiring a permanent pacemaker for Groups I and II.
Group III (conditions not addressed by NCD or contractor) requires attestation with Modifier -SC when billed.

Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
Implantation of a single-chamber or dual-chamber permanent cardiac pacemaker is covered for documented non-reversible symptomatic bradycardia due to second-degree and/or third-degree atrioventricular (AV) block.
Contractor-allowed (Group II) indications covered with attestation include symptomatic AV block, symptomatic first-degree AV block with PR interval >300 ms, and bundle branch/fascicular blocks when symptomatic or otherwise meeting contractor criteria.
Pacemaker implantation is allowed when used specifically to control supraventricular tachycardia (SVT) that is reproducibly terminated by pacing after failure or intolerance of catheter ablation and/or medical therapy.
Pacemaker implantation is allowed for atrial fibrillation/atrial flutter with symptomatic bradycardia that is due to necessary medical therapy (when no acceptable alternative exists), with attestation.
Pacemaker implantation is allowed for hypersensitive carotid sinus syndrome or neurocardiogenic syncope when there is a cardioinhibitory response of ≥3 seconds or significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or on tilt-table testing.

A54958 — Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker

J05

A57476 — Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)

J05

L34636 — Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)

J05

A56391 — Billing and Coding: Implantable Automatic Defibrillators

J05

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