00922
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Cross-reference: criteria related to cryopreservation are addressed in CP.MP.55 Assisted Reproductive Technologies (see that policy for cryopreservation requirements).
- For individuals with a female reproductive system aged ≥40 requesting retrieval of their own oocytes, documentation that the treating provider has evaluated: age, infertility risk factors, and a measure of ovarian reserve, and that the provider considers use of the member's own oocytes a viable strategy for attempting future conception.
- Documentation that the planned treatment causing risk to fertility is medically necessary.
- Clinical documentation supporting the diagnosis and planned gonadotoxic or fertility-threatening therapy (as referenced by policy sections I and III stating the treatment causing risk must be medically necessary).
Key Coverage Criteria
- General Anesthesia or Regional AnesthesiaAdministration of general or regional anesthesia is consideredmedically necessarywhen both of the following criteria are met:
- The services are provided by an individual other than the attending physician performing the procedure;and
- Alternative types of anesthesia, sedation, or analgesia are not appropriate.
- If general or regional anesthesia is requested for a procedure typically not requiring either of these levels of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.
- Monitored Anesthesia Care (MAC)Monitored anesthesia care (MAC) is consideredmedically necessarywhenallof the following criteria are met:
- MAC is requested by the attending physician;and
2 Active Policies
AMBETTER-CP.MP.130 — Fertility Preservation
ANTHEM-CG-MED-21 — CG-MED-21 Anesthesia Services and Moderate (âConsciousâ) Sedation
Related Codes
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