Does O12.20 require prior authorization?

No, O12.20 does not require prior authorization (high confidence). Code is covered without prior authorization.

`O12.20` — Gestational edema with proteinuria, unspecified trimester

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medical record must reflect how the cystatin C test result was used in the patient's plan of care.
Medical records must be maintained and legible, include complete patient identification and dates of service, and include the legible signature of the responsible physician or non-physician practitioner.
The submitted medical record must support the selected ICD-10-CM code(s) and show medical necessity for the cystatin C test.
The laboratory or billing provider must retain a physician requisition that states the diagnosis/ICD-10-CM code that warrants the test.

Cystatin C measurement is covered when medical record documents an adult patient (>=18 years) with a creatinine-based eGFR of 45–59 ml/min/1.73 m2 and no markers of kidney damage.
Cystatin C measurement is covered when the ordering documentation demonstrates that creatinine-based GFR estimates are believed to be inaccurate and more accurate GFR knowledge will affect clinical decision-making or the patient's plan of care.
Cystatin C testing is medically reasonable and necessary when all of the following are met: adult with serum creatinine–based eGFR 45–59 ml/min/1.73 m2 (CKD stage 3A) without markers of kidney damage; serum creatinine–based GFR is suspected to be inaccurate; and confirmation of GFR will affect clinical decisions (e.g., confirming CKD diagnosis, determining kidney donation eligibility, or adjusting dosage of renally excreted toxic drugs).
Determination of gestational age
Assessment of fetal number (e.g., multiple gestation)
Assessment of fetal viability

AMBETTER-CP.MP.38 — Ultrasound in Pregnancy

A57643 — Billing and Coding: Lab: Cystatin C Measurement

L37616 — Lab: Cystatin C Measurement

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