K76.5 — Hepatic veno-occlusive disease
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- For cases invoking AASLD-restricted indications (e.g., hepatic hydrothorax, refractory ascites), documentation of prior standard therapies and their failure/intolerance.
- Documentation of indications that meet the selection criteria (examples in Appendix): evidence that surgery is contraindicated when bleeding control from varices is required.
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
4 Active Policies
A57802 — Billing and Coding: Hepatic (Liver) Function Panel
AETNA-CPB-0259 — Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
Related Codes
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