42835
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.32
Facility
$183.37
Non-Facility
$183.37
Key Coverage Criteria
- Suspected adenoid tumor based on imaging (for example, CT), nasopharyngoscopy or endoscopy;or
- Adenoidectomy is consideredmedically necessaryfor individuals when any of the following conditions are met:
- Chronic (greater than or equal to 12 weeks in duration) adenoiditis with rhinorrhea, despite a minimum of 3 weeks of appropriate antibiotic treatment;or
- Chronic (greater than or equal to 12 weeks in duration) rhinosinusitis, despite a minimum of 3 weeks of appropriate antibiotic treatment and one or more of the following:CT findings suggestive of obstruction or infection (for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitus, or diffuse opacification);orNasal endoscopy findings suggestive of significant disease;orPhysical exam findings suggestive of chronic/recurrent disease (for example muc [...]
- CT findings suggestive of obstruction or infection (for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitus, or diffuse opacification);or
- Nasal endoscopy findings suggestive of significant disease;or
1 Active Policy
ANTHEM-CG-SURG-36 — CG-SURG-36 Adenoidectomy
Related Codes
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