Q64.9 — Congenital malformation of urinary system, 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.
- Documentation that the member meets the transplanting institution's selection criteria; OR if no institution criteria exist, documentation that both required numeric criteria are met: calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min, AND documented ESRD with current dialysis or expectation of requiring dialysis within the next 12 months.
- Record of the Cockcroft-Gault calculation inputs (age, weight in kg, serum creatinine in mg/dL) or directly measured GFR values to support creatinine clearance/GFR determination.
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-0587 — Pancreas Kidney Transplantation
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
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