86353
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- When relying on other CPBs (e.g., Acupuncture CPB 0135, Biofeedback CPB 0132, Chelation CPB 0234, Chiropractic CPB 0107, Electrical Stimulation CPB 0011), include documentation required per those CPBs (clinical notes, prior therapy trial details, objective findings) as applicable.
- For services listed as excluded or experimental/investigational, include documentation if an exception is being requested (e.g., supporting literature, rationale for use outside usual practice) though the CPB states these are considered experimental/investigational and not supported.
- No explicit documentation requirements are specified in the provided document text.
- Coverage of alternative medicine interventions is 'subject to applicable benefit plan limitations and exclusions' and requires that interventions be 'supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature' and used for 'properly selected members' (implying clinical justification and supporting literature should be present in the medical record).
Key Coverage Criteria
- Augmented soft tissue mobilization (ASTM) — considered proven non-preferentially for physical therapy (i.e., considered a proven physical therapy approach but no reliable evidence it is superior to other providers).
- Chelation therapy - see CPB 0234 - Chelation Therapy
- Chiropractic services - see CPB 0107 - Chiropractic Services
- Electrical stimulation - see CPB 0011 - Electrical Stimulation for Pain
- Aetna considers Airrosti (Applied Integration for the Rapid Recovery of Soft Tissue Injuries) and augmented soft tissue mobilization (ASTM) as proven non-preferentially for physical therapy (i.e., considered proven but lack of evidence of superiority to other physical therapy providers).
- Aetna considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature.
8 Active Policies
AETNA-CPB-0388 — Complementary and Alternative Medicine
MED207.088 — Intracellular Micronutrient Analysis
CIGNA-EN0086 — Complementary and Alternative Medicine - (EN0086)
AETNA-CPB-0348 — Recurrent Pregnancy Loss
BCBSIL-MED207.088 — Intracellular Micronutrient Analysis
Related Codes
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