Does 88319 require prior authorization?

No, 88319 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 88319?

Medicare facility rate: $131.93. Non-facility rate: $131.93. Work RVU: 0.52.

Verity

`88319`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.52

Facility

$131.93

Non-Facility

$131.93

Documentation Required

Implicit: because the CPB deems the listed uses experimental/investigational, documentation showing medical necessity for non‑experimental, evidence‑based indications is not described or endorsed.
No specific documentation requirements, test result thresholds, or required clinical record elements are specified in this policy bulletin for covered use. (Policy treats the listed measurements as experimental/investigational and not covered.)
Clinical indication and relevant clinical history supporting the need for the special stain or IHC (e.g., suspected or known tumor type/site, diagnostic question to be answered).
Description of specimen type and anatomic site (e.g., bladder, breast, bone marrow) and correlation with H&E findings that justify the special stain/IHC.

Key Coverage Criteria

No biochemical markers of bone remodeling are identified in this Clinical Policy Bulletin as established/covered for evaluation of fracture risk; Aetna considers measurement of the listed bone turnover markers for evaluating fracture risk experimental and investigational.
Aetna considers measurement of the following specific bone turnover markers experimental and investigational for evaluating fracture risk (list not all-inclusive): Bone sialoprotein; Cathepsin K; Cobalamine (Vitamin B12); Dickkopf-related protein 1 (DKK-1); Hydroxyproline; Insulin-like growth factor-1 (IGF-1); Osteocalcin; Osteoprotegerin; Procollagen type I amino terminal propeptide (P1NP); Pyridinium crosslinks (pyridinoline, deoxypyridinoline); Receptor activator of nuclear factor kappa-B lig [...]
No biochemical markers (including serum or urinary collagen crosslinks or other BTMs) are established/covered for routine screening, diagnosis, or management of osteoporosis according to this CPB.
Aetna considers measurement of bone turnover markers experimental and investigational for diagnosis and monitoring of aseptic loosening and/or osteolysis related to wear or corrosion in total joint arthroplasty.
Aetna considers measurement of bone turnover markers experimental and investigational for persons receiving serotonergic antidepressants (i.e., NOT established/covered for evaluating bone effects in this population).
Aetna considers measurement of collagen crosslinks experimental and investigational for screening, diagnosis, or management of bisphosphonate-induced jaw osteonecrosis, chronic kidney disease, osteogenesis imperfecta, or other indications.

2 Active Policies

HUMANA-SPECIAL-STAINS-MA — Special Stains - Medicare Advantage

AETNA-CPB-0562 — Biochemical Markers of Bone Remodeling

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88319