A58 — Granuloma inguinale
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Avian influenza A virus (H5N1): documentation of symptoms consistent with Avian influenza A virus and history of travel to or contact with persons or birds from a country with documented H5N1 avian influenza infections within 10 days of symptom onset.
- Cerebrospinal fluid (CSF) pathogen panel: Member has clinical findings consistent with a central nervous system (CNS) infection (e.g., meningitis, encephalitis); and viral etiology is suspected or the CSF culture is inconclusive for pathogen etiology (i.e., viral, bacterial, fungal).
- Coronavirus COVID-19 respiratory panel (up to 5 respiratory pathogens): Member has signs and symptoms of COVID-19 and test will be used to guide therapy.
- Gastrointestinal pathogen panel: documentation that member has community-acquired diarrhea of 7 days or more duration; or travel-related diarrhea; or diarrhea with signs or risk factors for severe disease (fever, bloody diarrhea, dysentery, dehydration, severe abdominal pain, hospitalization and/or immunocompromised state). For >11-target panels documentation that member is critically ill or immunocompromised. For >11-target panels R19.7 (diarrhea, unspecified) is required for claims.
Key Coverage Criteria
- Acanthamoeba in corneal ulceration
- Actinomyces, for identification of actinomyces species in tissue specimens
- Adenovirus, to diagnose adenovirus myocarditis, and to diagnose adenovirus infection in immunocompromised hosts, including transplant recipients
- Anaplastic lymphoma kinase (ALK) testing as an alternative to FISH for selecting individuals for ALK inhibitor therapy
- Avian influenza A virus, for diagnosis of avian influenza A (H5N1) in persons with both: Symptoms consistent with Avian influenza A virus (see background); and A history of travel to or contact with persons or birds from a country with documented H5N1 avian influenza infections within 10 days of symptom onset.
- Babesiosis (Babesia spp.), diagnosis
1 Active Policy
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
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