Z68.54 — Body mass index [BMI] pediatric, 95th percentile for age to less than 120% of the 95th percentile for age
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No documentation requirements are specified in this Clinical Policy Bulletin. (The document does not list required medical records, test results, or specific clinical documentation for coverage because the service is classified as experimental/investigational and not covered for the listed indications.)
- No explicit medical record or documentation requirements are specified in this document/chunk
- No documentation requirements are specified in this excerpt.
- Documentation of the diagnosis/indication prompting nutritional counseling (e.g., obesity, overweight with documented BMI and specified CVD risk factors, diabetes mellitus, eating disorder, gastrointestinal disorder, hypertension, kidney disease, seizures, COPD, ESRD).
Key Coverage Criteria
- children and adolescents with mental illness
- Mounted equine-assisted therapies (horse riding) as a component of EAT programs
- Stroke (post-stroke hemiparesis; post-stroke patients in the 1st year post-stroke)
- post-stroke patients with hemiparesis
- therapeutic horseback riding / hippotherapy applied as a supplement to conventional physiotherapy
- Note: The document also discusses applications or study populations including cerebral palsy, autism spectrum disorder, multiple sclerosis, Down syndrome, attention-deficit/hyperactivity disorder (ADHD), chronic pain, breast cancer survivors, posttraumatic stress disorder, substance use disorder, and other neurologic/psychiatric populations (these appear as referenced study populations in the literature list)
5 Active Policies
AMBETTER-CP.MP.157 — 25-hydroxyvitamin D Testing in Children and Adolescents
AMBETTER-CP.MP.154 — Thyroid Hormones and Insulin Testing in Pediatrics
AETNA-CPB-0049 — Nutritional Counseling
AETNA-CPB-0151 — Hippotherapy
ANTHEM-CG-LAB-11 — CG-LAB-11 Vitamin D Testing
Related Codes
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