Does Q43.2 require prior authorization?

No, Q43.2 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Q43.2` — Other congenital functional disorders of colon

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.

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/sigmoidoscopy/proctosigmoidoscopy is covered to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, or inadequate exam).
Evaluation of unexplained gastrointestinal bleeding, including hematochezia not thought to be from a rectal/perianal source or melena of unknown origin, is covered.
Colonoscopy is covered for investigation of a positive fecal occult blood test.
Evaluation of unexplained iron deficiency anemia is covered when colon evaluation is clinically indicated.

AETNA-CPB-0113 — Botulinum Toxin

AETNA-CPB-0396 — Gastrointestinal Function: Selected Tests

A56421 — Billing and Coding: CT of the Abdomen and Pelvis

A56456 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

A56632 — Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

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