I67.4 — Hypertensive encephalopathy
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
- Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
- A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.
Key Coverage Criteria
- Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
- Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
- For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.
20 Active Policies
L35753 — Non-Invasive Cerebrovascular Studies
J05
A57592 — Billing and Coding: Non-Invasive Cerebrovascular Studies
J05
A57483 — Billing and Coding: Visual Fields
J05
L34615 — Visual Fields
J05
A56551 — Billing and Coding: Visual Fields Testing
Related Codes
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