49185
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.29
Facility
$105.21
Non-Facility
$1206.44
Documentation Required
- If repeat injections are performed for recurrent cyst, documentation of recurrence and timing (note: repeat injections may be medically necessary after 1 month in cases of recurrence).
- For thyroglossal duct cysts, documentation must demonstrate the selection criteria: 'A monocystic lesion is present; and Cystographic studies indicate that there is no extravasation; and Cytologic studies show that the lesion is benign.'
- Documentation of recurrence when repeat injection is performed (policy note: may be medically necessary to repeat injections after 1 month in cases of recurrence of cyst).
- For symptomatic venous malformations of the head and neck, documentation of symptoms and diagnosis (policy references clinical diagnosis and imaging confirmation in supporting literature; the policy states TEI is 'medically necessary' for symptomatic lesions).
Key Coverage Criteria
- Aetna considers ethanol injection sclerotherapy medically necessary for the treatment of thyroglossal duct cysts when all of the following selection criteria are met: A monocystic lesion is present; and Cystographic studies indicate that there is no extravasation; and Cytologic studies show that the lesion is benign.
- It may be medically necessary to repeat injections after 1 month in cases of recurrence of cyst.
- Aetna considers ethanol injection sclerotherapy medically necessary for symptomatic venous malformations of the head and neck.
- Aetna considers absolute ethanol injection medically necessary for overt upper gastro-intestinal bleeding.
- Covered ICD-10 diagnoses listed in the policy for covered indications: Q89.2 (Congenital malformations of other endocrine glands [thyroglossal duct cyst]), K28.0–K28.9 (Gastrojejunal ulcer [Overt upper gastrointestinal bleeding]), K29.71 (Gastritis, unspecified, with bleeding [Overt upper gastrointestinal bleeding]), K92.2 (Gastrointestinal hemorrhage, unspecified [Overt upper gastrointestinal bleeding]).
- Percutaneous aspiration with sclerotherapy (PAS) for symptomatic simple hepatic cysts (SHC)
2 Active Policies
AETNA-CPB-0395 — Ethanol Injection for Thyroid Lesions and Other Selected Indications
AETNA-CPB-0207 — Prolotherapy and Sclerotherapy
Related Codes
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