Does 95975 require prior authorization?

No, 95975 does not require prior authorization (high confidence). Code is covered without prior authorization.

`95975`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

If billing using ICD-10 codes listed as 'covered if selection criteria are met', documentation must support that the patient meets the selection criteria referenced in the policy (see above).
ICD-10 diagnosis coding consistent with covered codes (e.g., I69.051-I69.059; I69.151-I69.159; I69.251-I69.259; I69.351-I69.359; I69.851-I69.859; I69.951-I69.959; I69.331-I69.339) should be present when selection criteria are met (policy lists these codes as covered if selection criteria are met).
Document baseline and post-treatment objective measures of motor function (examples cited: Action Research Arm Test (ARAT), Nine Hole Peg Test, Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), Assisting Hand Assessment (AHA), Quality of Upper Extremity Skills Test (QUEST), Wolf Motor Function Test (WMFT), Pediatric Motor Activity Log-Revised (PMAL-R), Melbourne Assessment of Unilateral Upper Limb Function (MUUL), 9-Hole Peg Test, hand grip strength, Box & Block Test).

Multiple sclerosis with chronic upper extremity hemiparesis (pilot and phase II trials reported benefit).
Constraint-induced movement therapy (CIMT) is considered medically necessary for the treatment of upper limb hemiparesis in persons with stroke who have at least 10 degrees of active wrist and finger extension, and who have no sensory and cognitive deficits.
Pediatric hemiplegia from causes including perinatal stroke, traumatic brain injury, brachial plexus birth injury (BPBI / OBPP / PBPP), and brain tumors (pilot/feasibility studies reported).
Lower extremity CIMT approaches for lower limb hemiparesis/impairment (stroke, MS — preliminary/lower extremity studies).
Use as an adjunct to other interventions (e.g., paired with peripheral nerve stimulation (PNS), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), biofeedback, electroacupuncture) to augment motor recovery (pilot and early clinical trials reported).
Stroke (ischemic and unspecified): constraint-induced movement therapy (CIMT) for improving upper extremity function (acute, subacute and chronic stroke populations referenced throughout citations)

AETNA-CPB-0665 — Constraint-Induced Therapy

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