Does Z86.004 require prior authorization?

No, Z86.004 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Z86.004` — Personal history of in-situ neoplasm of other and unspecified digestive organs

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 article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, 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.
A colonoscopy may be billed when a sigmoidoscope is used only if the bowel is sufficiently short that the entire colon can be examined and this fact is clearly documented in the clinical record.
An incomplete colonoscopy (inability to advance the colonoscope to the cecum or colon‑small intestine anastomosis due to unforeseen circumstances) is billed using codes 44388, 45378, G0105 or G0121 with modifier -53.
When the colonoscopy procedure is unusual or difficult, report modifier -22 (unusual procedural services) on the claim.

L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic

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A58756 — Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

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L39040 — MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

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A56394 — Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic

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