59070
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
5.11
Facility
$275.56
Non-Facility
$403.48
Documentation Required
- Informed consent documentation (including counseling about experimental/not proven indications when applicable)
- Documentation of prior management and rationale for amnioinfusion (e.g., prior conservative measures, reason amnioinfusion is being performed)
- If performed for indications considered experimental/investigational, documentation of enrollment in an approved clinical trial or that the procedure is provided only as an approved innovation/research (the CPB notes such indications are experimental/investigational because of insufficient evidence)
- Clinical documentation of the specific covered indication (e.g., oligohydramnios, variable decelerations due to cord compression, pPROM) must be present in the medical record.
Key Coverage Criteria
- Prophylactic treatment of oligohydramnios.
- Reduction of variable decelerations of the fetal heart rate because of cord compression during labor.
- Treatment of preterm premature rupture of membranes (pPROM) at 26 weeks' gestation or later.
- Procedure/CPT covered when selection criteria are met: 59070 Transabdominal amnioinfusion, including ultrasound guidance.
- ICD-10 diagnoses listed as covered when selection criteria are met: O41.00x0 - O41.00x9 (Oligohydramnios).
- ICD-10 diagnoses listed as covered when selection criteria are met: O42.011 - O42.92 (Premature rupture of membranes) [only covered at 26 weeks gestation or later].
1 Active Policy
AETNA-CPB-0417 — Amnioinfusion
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.