00122
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Documented IIH diagnosis;and
- Venous angioplasty with or without stent placement or venous stenting alone is consideredmedically necessaryfor treatment of the following conditions:
- Venous thoracic outlet syndrome;or
- Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome);or
- Superior vena cava syndrome;or
- Iliac vein compression syndrome (for example, May-Thurner Syndrome);or
1 Active Policy
ANTHEM-CG-SURG-106 — CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
Related Codes
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