N81.10 — Cystocele, unspecified
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.
- If MR defecography is proposed, documentation must address the reasons for choosing MR (note: MR defecography is considered investigational for CPB-listed indications and MR-related CPTs are listed as not covered for CPB indications).
- Documented chronic constipation as defined in the policy: presence of 2 or more of the following symptoms for at least 3 months: 'Lumpy and/or hard stools at least 1/4 of the time; or Sensation of incomplete evacuation at least 1/4 of the time; or Straining at defecation at least 1/4 of the time; or Two or fewer bowel movements per week.'
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.
3 Active Policies
AETNA-CPB-0718 — Defecography
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
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