A20.0 — Bubonic plague
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The CPB references clinical assessment methods used in studies (e.g., clinical signs and symptoms [CSS], NERDS/STONEES/UPPER/LOWER checklists, microbiological swabs, biopsies) but does not mandate these as documentation requirements for coverage.
- The CPB does not specify formal documentation requirements or required medical-record elements for coverage determination.
Key Coverage Criteria
- MolecuLight, a hand-held device, for point-of-care fluorescence imaging of wounds
- Noncontact, nonthermal, low-frequency ultrasound therapy for the treatment of wounds and all other indications (e.g., bacterial infections, deep tissue pressure injury, and femoral artery thrombosis)
- Warm-Up Active Wound Therapy, also known as noncontact normothermic wound therapy (NNWT) and warming therapy
- None — The CPB states the following are considered experimental and investigational because effectiveness has not been established: MolecuLight (hand-held device) for point-of-care fluorescence imaging of wounds; noncontact, nonthermal, low-frequency ultrasound therapy for the treatment of wounds and all other indications; Warm-Up Active Wound Therapy (noncontact normothermic wound therapy / NNWT / warming therapy).
- Exposure to hepatotoxins;or
- Gastrointestinal disease;or
3 Active Policies
AETNA-CPB-0372 — Noncontact Normothermic/Nonthermal Wound Therapy and Noncontact Fluorescence Imaging of Wounds
ANTHEM-CG-LAB-29 — CG-LAB-29 Gamma Glutamyl Transferase Testing
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
Related Codes
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