79005
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.76
Facility
$132.27
Non-Facility
$132.27
Documentation Required
- Parathyroid localization enhanced by dual-isotope subtraction and/or ultrasound with iPTH assay in US-guided FNA: documentation of ultrasound and iPTH aspirate results when performed to direct surgical approach.
- Sentinel node procedures: documentation of preoperative lymphoscintigraphy (when performed), intraoperative lymphatic mapping technique, and definitive histopathology of sentinel node(s) (only individuals with histologically confirmed sentinel node metastases are selected for radical node dissection).
- AdreView (iobenguane I-123) diagnostic standard: “The diagnosis was determined by histopathology or, when histopathology was unavailable, a composite of imaging, plasma/urine catecholamine and/or catecholamine metabolite measurements and clinical follow-up.” (implies need for histopathology or detailed composite diagnostic documentation).
Key Coverage Criteria
- ProstaScint scans medically necessary for pre-operative staging of newly diagnosed members with biopsy-proven prostate cancer that is thought to be clinically localized after standard diagnostic evaluation, but who have a moderate to high probability of occult extra-prostatic metastasis.
- ProstaScint scans medically necessary for staging of post-prostatectomy members or members treated with radiation therapy in whom there is a high suspicion of undetected residual prostate cancer or cancer recurrence.
- Oncoscint (satumomab pendetide) imaging medically necessary as an alternative to second-look laparotomy to detect occult colorectal carcinoma in members with suspected recurrence suggested by an elevated carcino-embryonic antigen (CEA) level, but who have no evidence of disease on conventional imaging modalities (including CT scan).
- Oncoscint imaging medically necessary for detection of occult colorectal carcinoma in members about to undergo a potentially curative resection of an apparently isolated recurrence located at a single site (e.g., lung or liver) which has been identified on conventional imaging modalities (including CT scan) and for whom the detection of occult lesions elsewhere would alter the surgical management.
- Oncoscint imaging medically necessary for detection of occult recurrent ovarian cancer in members with suspected recurrence suggested by rising tumor markers, when no other imaging or physical examination technique can locate the suspected disease.
- CEA-Scan (Tc-99m-arcitumomab) medically necessary, for use in conjunction with computerized tomography (CT) scans, for detection of recurrent or metastatic colorectal cancer in the liver and extra-hepatic abdomen and pelvis.
4 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
AETNA-CPB-0168 — Tumor Scintigraphy
CARELON-therapeutic-radiopharmaceuticals-2022-11-06 — Therapeutic Radiopharmaceuticals
CARELON-therapeutic-radiopharmaceuticals-2025-03-23 — Therapeutic Radiopharmaceuticals
Related Codes
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