Q55.21 — Polyorchism
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.
- Refills based upon documentation in cycle sheets.
- Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be 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.
3 Active Policies
AETNA-CPB-0327 — Infertility
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
Related Codes
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