A42.9 — Actinomycosis, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Chronic sinusitis (for example, greater than 12 weeks duration) that interferes with lifestyle;and
- Functional endoscopic sinus surgery (FESS) is consideredmedically necessarywhenany oneof the following circumstances is present:
- Suspected tumor seen on imaging, physical examination, or endoscopy;or
- Suppurative (pus forming) complications, including but are not limited to:Subperiosteal abscess;orBrain abscess;or
- Subperiosteal abscess;or
- Brain abscess;or
3 Active Policies
ANTHEM-CG-SURG-24 — CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
ANTHEM-CG-LAB-29 — CG-LAB-29 Gamma Glutamyl Transferase Testing
Related Codes
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