96379
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
- “The word ‘PUMP’ should be entered in the REMARKS section of the CMS-1450 (UB-04) claim form or the electronic equivalent to indicate the claim is for use of an external pump for the administration of prolonged drug infusion services.”
- “The word ‘PUMP’ should be entered in block 19 on the CMS-1500 claim form or the electronic equivalent to indicate the claim is for use of an external pump for the administration of prolonged drug infusion services.”
- “It is not necessary to include the word ‘PUMP’ in block 19 or the equivalent section for electronic claims.”
- None specified in this policy bulletin.
Key Coverage Criteria
- None — Aetna considers histamine desensitization therapy (e.g., intravenous histamine infusion or subcutaneous injection of histamine) experimental and investigational for the treatment of intractable headaches (e.g., chronic cluster headaches and migraines) or other indications because its effectiveness has not been established by randomized controlled studies.
- Cutaneous melanoma — as high-dose single-agent subsequent therapy for metastatic or unresectable disease
- Metastatic melanoma (FDA‑approved indication for treatment of adults with metastatic melanoma)
- Metastatic renal cell carcinoma with clear cell histology (FDA‑approved indication for treatment of adults with metastatic renal cell carcinoma)
- Chronic graft‑versus‑host disease (GVHD) — for treatment as additional therapy in conjunction with systemic corticosteroids following no response to first‑line therapy options
- Neuroblastoma — for treatment of neuroblastoma (see CPB 0895 - Dinutuximab (Unituxin))
5 Active Policies
A55134 — Billing and Coding: Prolonged Drug and Biological Infusions Started Incident To a Physicians Service Using an External Pump
J12
CIGNA-EN0086 — Complementary and Alternative Medicine - (EN0086)
AETNA-CPB-0024 — Aldesleukin (Proleukin)
AETNA-CPB-0647 — Histamine Desensitization Therapy for Intractable Headaches
ANTHEM-MED.00098
Related Codes
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