Does K60.40 require prior authorization?

No, K60.40 does not require prior authorization (high confidence). Code is covered without prior authorization.

`K60.40` — Rectal fistula, unspecified

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

When performed for surveillance of colonic neoplasia, report the appropriate CPT/HCPCS procedure code and the appropriate primary ICD-10-CM code plus one of the following secondary diagnosis codes: Z85.038, Z85.048, Z86.0100, Z86.0101, Z86.0102, or Z86.0109.
For high-risk post-surgical follow-up at 1 year (with continued 24-month screening eligibility), report HCPCS code G0105 as the appropriate screening/high-risk colonoscopy code.
When performing endoscopy for indications that are generally not covered, submit additional documentation evidencing the medical necessity of the procedure for review.
Provider/supplier must notify the beneficiary in writing prior to rendering the service if the provider is aware the test/procedure may not be covered by Medicare; limitation of liability and refund requirements apply when denials are likely.

Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
Colonoscopy to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, inadequate exam).
Evaluation of unexplained gastrointestinal bleeding including hematochezia not thought to be from a rectal/perianal source, melena of unknown origin, or presence of fecal occult blood.
Evaluation of unexplained iron deficiency anemia.
Surveillance examination of the entire colon to evaluate for synchronous colonic cancer or polyps in a patient with treatable cancer or polyps.

AETNA-CPB-0244 — Skin and Soft Tissue Substitutes

A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

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