55842
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
20.83
Facility
$1042.78
Non-Facility
$1042.78
Documentation Required
- No specific documentation requirements, prior authorization criteria, or required clinical documentation are stated in this CPB. (Policy contains literature review, statements of experimental/investigational status, and lists of CPT/HCPCS/ICD-10 codes not covered, but does not specify required documentation fields.)
- No documentation requirements specified in this document.
- No documentation requirements (medical records, test results, or specific clinical documentation) are specified in the provided text.
- In order to determine medical necessity consistently, Humana and subsidiaries may consider the criteria contained in the following: (text indicates additional criteria/documentation will be used but the criteria are not included in this excerpt).
Key Coverage Criteria
- Prompt repair of acute phrenic nerve transection due to trauma or surgery. (Note in policy: "Phrenic nerve reconstruction for the treatment of diaphragmatic paralysis (Note: this does not apply to prompt repair of acute phrenic nerve transection due to trauma or surgery)")
- No other specific indications are affirmatively listed as covered in this CPB; multiple nerve grafting and nerve reconstruction interventions are described in the literature review but are explicitly identified in this policy as experimental and investigational (see Limitations).
- Radical perineal prostatectomy with lymph node biopsy(s) (limited pelvic lymphadenectomy) — CPT 55812
- Open prostatectomy is a surgical procedure where the surgeon removes the prostate through an incision in the lower abdomen or, less commonly, through a perineal incision.
- Humana and subsidiaries follow the Medicare requirements that only allow coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.
- Localized prostate cancer (confined to the prostate gland).
7 Active Policies
HUMANA-PROSTATECTOMY-MA — Prostatectomy - Medicare Advantage
AETNA-CPB-0416 — Nerve Grafting and Reconstruction: Selected Indications
BCBSIL-SUR710.019 — Nerve Graft with Radical Prostatectomy
BCBSMT-SUR710.019 — Nerve Graft with Radical Prostatectomy
BCBSNM-SUR710.019 — Nerve Graft with Radical Prostatectomy
Related Codes
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