64681
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.69
Facility
$193.06
Non-Facility
$462.27
Documentation Required
- None specified in the CPB. (The document does not list explicit medical record, test result, or clinical documentation requirements for coverage or for investigational determinations.)
- Diagnosis documentation of post-herpetic neuralgia (PHN) — clinical diagnosis typically from 'typical unilateral dermatomal pain and rash' and PHN defined in background as 'significant pain or dysaesthesia present 3 months or more following HZ.'
- When billing CPT/HCPCS codes listed as 'covered if selection criteria are met,' documentation must demonstrate that the applicable selection criteria are met (policy: 'CPT codes / HCPCS codes / ICD-10 codes — CPT codes covered if selection criteria are met').
- For use of Qutenza (capsaicin 8% patch): documentation that the patch was applied by a health care professional, the most painful skin areas treated, number of patches used (up to 4), duration of application (60 minutes), and monitoring for at least 1 hour post-application due to blood pressure risk ('Qutenza must be applied to the skin by a health care professional... The patient must also be monitored for at least 1 hour...').
Key Coverage Criteria
- Endometriosis
- None explicitly listed as covered in this CPB. The policy identifies the following procedures as experimental and investigational (i.e., effectiveness not established and thus not supported by this policy): dorsal root ganglion stimulation; hypogastric plexus neurolysis for the treatment of chronic pelvic pain associated with endometriosis; peritoneal excision (stripping) for the treatment of endometriosis; uterine nerve ablation (UNA), laparoscopic uterine nerve ablation (LUNA) and presacral n [...]
- Other indications related to pelvic pain addressed by selected treatments (policy scope: selected treatments for chronic pelvic pain, endometriosis, and other indications)
- Post-herpetic neuralgia (PHN).
- Aetna considers the use of antivirals (oral), gabapentin, intrathecal, interlaminar or transforaminal epidural corticosteroids, lidocaine patch, opioids (oral), pregabalin, and tricyclic anti-depressants medically necessary for post-herpetic neuralgia (PHN).
- CPT/HCPCS codes listed in the policy are covered if selection criteria are met (see 'CPT Codes / HCPCS Codes / ICD-10 Codes' section).
2 Active Policies
AETNA-CPB-0725 — Post-Herpetic Neuralgia
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
Related Codes
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