96367
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.19
Facility
$29.73
Non-Facility
$29.73
Documentation Required
- Medical record documentation of a complete history and physical examination.
- Documented parent/child interview or patient interview containing DSM-5 diagnostic criteria and findings.
- Results of collateral assessments when available (for example, Vanderbilt or Conners questionnaires).
- Psychiatric evaluation report or clinical notes from psychiatrist, psychologist, or other behavioral health professional.
Key Coverage Criteria
- A course of up to 4 weeks of intravenous (IV) antibiotic therapy is consideredmedically necessaryfor individuals with Lyme disease meetingBOTHcriteria AandB below:
- The condition to be treated isONEof the following (1, 2,or3):Myocarditis associated with any of the following:First-degree heart block when the PR interval is prolonged to 300 milliseconds or greater;orSecond-degree atrioventricular block;orThird-degree atrioventricular block;orPersistent or recurrent joint swelling (that is, arthritis) after an initial 1 month trial of oral antibiotics;orAcute or chronic neurological disease affecting the central or peripheral nervous system, includingANYof the [...]
- Myocarditis associated with any of the following:First-degree heart block when the PR interval is prolonged to 300 milliseconds or greater;orSecond-degree atrioventricular block;orThird-degree atrioventricular block;or
- First-degree heart block when the PR interval is prolonged to 300 milliseconds or greater;or
- Second-degree atrioventricular block;or
- Third-degree atrioventricular block;or
2 Active Policies
AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment
ANTHEM-CG-MED-98 — CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease
Related Codes
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