A32.9 — Listeriosis, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For intrathecal baclofen: 'The patient should be shown to respond to a single intrathecal bolus dose of up to 100 mcgs of baclofen. A positive response is defined as an average two-point drop on an objective muscle tone or spasm screening system (e.g., The Ashworth and Spasm scale).'
- Pre-implantation requirements for spinal analgesia: 'To be considered for spinal analgesia, a patient must have a normal platelet count and no coagulation disorder, infection, or other problems that might preclude the use of spinal drugs.'
- Intrahepatic chemotherapy: documentation supporting diagnosis of primary hepatocellular carcinoma or metastatic colorectal cancer limited to the liver and clinical justification for intrahepatic infusion.
- Trialing before permanent intrathecal pump implantation: 'Before the implantation of a permanent infusion system, an efficacy test is usually performed to assess the patient's response and dose. One or several trial doses of 5 to 10 mg of epidural morphine, or 0.5 to 1.0 mg intrathecal morphine is/are administered while all other analgesic medications are stopped. Subjective pain ratings and undesirable side effects are evaluated for several days.'
Key Coverage Criteria
- G89.4 Chronic pain syndrome
- G95.11 - G95.19 Vascular myelopathies
- O88.011 - O88.83 Obstetric embolism
- External infusion pumps (only) for deferoxamine for treatment of acute iron poisoning and iron overload.
- G82.50 - G82.54 Quadriplegia
- Implanted infusion pumps are medically necessary durable medical equipment (DME) when: the drug is medically necessary for the treatment of the member; it is medically necessary that the drug be administered by an implanted infusion pump; and the infusion pump has been approved by the FDA for infusion of the particular drug that is to be administered.
2 Active Policies
AETNA-CPB-0161 — Infusion Pumps
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
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