85055
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Immune cell counts: B cells total (86355), Natural killer (NK) cells total (86357), T cells total (86359), absolute CD4 and CD8 count including ratio (86360), absolute CD4 count (86361) — listed as related tests (documentation of immune status when indicated)
- Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy (CPT 88233) — listed as related diagnostic procedure
- Pulmonary function testing where relevant: Measurement of lung volumes in infant/child through 2 years (CPT 94013); Plethysmography for lung volumes/airway resistance (94726); Gas dilution/washout for lung volumes and distribution of ventilation (94727); Airway resistance by oscillometry (94728) — listed as related tests (documentation requirement for pulmonary assessment)
- Leukocyte and urinary glycosaminoglycan (uGAG) excretion testing: CPT 85048 (leukocyte testing) and CPT 83864 (Mucopolysaccharides, acid, quantitative) — listed as diagnostic tests for mucopolysaccharidoses
Key Coverage Criteria
- E74.02 — Pompe disease [Pompe disease] (alglucosidase alfa, Lumizyme)
- E76.01 - E76.03 — Mucopolysaccharidosis, type I [Hurler's, Hurler‑Scheie and Scheie's syndrome] [with moderate to severe symptoms]
- E75.240 - E75.249 — Niemann‑Pick disease [Acid sphingomyelinase deficiency (ASMD)]
- E75.21 — Fabry (-Anderson) disease
- E76.29 — Other mucopolysaccharidosis [MPS VI]
- General: Precertification of enzyme replacement drugs required of all Aetna participating providers and members in applicable plan designs (call (866) 752-7021 or fax (888) 267-3277).
1 Active Policy
AETNA-CPB-0442 — Lysosomal Storage Disorder Treatments
Related Codes
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