Does T18.5XXD require prior authorization?

No, T18.5XXD does not require prior authorization (high confidence). Code is covered without prior authorization.

`T18.5XXD` — Foreign body in anus and rectum, subsequent encounter

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

The medical record must document the medical reasonableness, necessity, and clinical frequency of the diagnostic colonoscopy or sigmoidoscopy and be available to the Contractor upon request.
Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.
Refer to associated LCD L34614 and Medicare IOM for additional coverage and documentation guidance for colorectal cancer screening procedures.
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.

Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
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.

A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

J05

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

J05

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

L34415 — CT of the Abdomen and Pelvis

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