0562T — Antmc guide 3d print ea addl
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
- Documentation demonstrating the therapy is proven effective for the relevant diagnosis or procedure.
- For drug therapy, documentation of the proposed dose, frequency, and duration plus citation or evidence from at least one authoritative source (e.g., FDA labeling, MCG, DrugDex, NCCN).
- Preoperative three-dimensional CT or MRI scan performed and available (images obtained approximately 4–6 weeks before surgery).
- Imaging files/plans sent to the planner/manufacturer and retained.
Key Coverage Criteria
- Therapies that are proven effective for the relevant diagnosis or procedure are considered for coverage.
- Drug therapies when proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source.
- Interventions supported by FDA-approved labeling or nationally recognized authoritative references (e.g., MCG, DrugDex, NCCN) are considered under this policy.
- Use of patient-specific cutting guides for individuals undergoing knee arthroplasty as an alternative to or improvement on existing therapies
- Partial or total knee arthroplasty for individuals with advanced arthritis causing significant, disabling pain
- Knee arthroplasty to improve functional status and quality of life in patients with symptomatic end-stage knee disease
5 Active Policies
BCBSIL-SUR705.037 — Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
BCBSMT-SUR705.037 — Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
BCBSNM-SUR705.037 — Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
BCBSOK-SUR705.037 — Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
SUR705.037
Related Codes
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