Does 86628 require prior authorization?

No, 86628 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 86628?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`86628`

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

Documentation of response to any treatments given, including validated outcome measures where applicable (fatigue scales, SF-36, CIS-fatigue, etc.) and any adverse events.
Mental status examination to identify abnormalities in mood, intellectual function, memory and personality; if psychiatric/neurologic/cognitive disorder is suspected, obtain an appropriate psychiatric, psychological, or neurological evaluation: "Evidence of psychiatric, neurologic or cognitive disorder requires that an appropriate psychiatric, psychological, or neurological evaluation be done."
Documentation that the patient meets clinical case definition criteria (e.g., CDC/Fukuda criteria): "Patients with CFS must have clinically evaluated, unexplained, persistent, or relapsing fatigue plus four or more specifically defined associated symptoms."

Key Coverage Criteria

Evaluation of members suspected of having chronic fatigue syndrome (CFS).
Aetna considers the following as medically necessary exclusionary tests to be used for the evaluation of members suspected of having chronic fatigue syndrome (CFS) as recommended by the National Institutes of Health. The selection of studies depends on the specific characteristics of a given case:
Anti-nuclear antibodies (ANA)
Blood and serum chemistries (blood urea nitrogen, calcium, creatinine, glucose, serum electrolytes)
Complete blood count (CBC) with differential cell count
Erythrocyte sedimentation rate (ESR)

2 Active Policies

AMBETTER-CP.MP.100 — Allergy Testing

AETNA-CPB-0369 — Chronic Fatigue Syndrome

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Results of the recommended limited laboratory testing when performed: "complete blood count with differential count," "erythrocyte sedimentation rate," "chemistry screen," "thyroid stimulating hormone level," ‘‘anti-nuclear antibodies,’’ and "urinalysis," and documented indication/results for any additional tests performed (rheumatoid factor, immunoglobulin levels, tuberculin skin test, Lyme serology if endemic area, HIV serology, MRI head if indicated, polysomnography if indicated).

86628