A69.1 — Other Vincent's infections
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Speech-language pathology (SLP) assessment documenting baseline voice characteristics, perceptual evaluations, and planned therapy approach
- Patient self-assessment measures such as Voice Handicap Index (VHI), VHI-10, Voice-Related Quality of Life (V-RQOL) or other validated patient-reported outcome measures, recorded pre- and post-therapy
- Acoustic and aerodynamic objective measures where appropriate (e.g., jitter, shimmer, noise-to-harmonics ratio, Dysphonia Severity Index [DSI], Acoustic Voice Quality Index [AVQI], maximum phonation time [MPT], phonation quotient, relative fundamental frequency [RFF])
- Documented trial of conservative management where appropriate (e.g., voice rest, vocal hygiene, indirect therapy) and results of that trial prior to or alongside proceeding to more invasive therapy or surgery
Key Coverage Criteria
- Essential voice tremor
- Paradoxical vocal fold motion (vocal cord dysfunction) — voice therapy focusing on vocal cord relaxation techniques and breathing exercises
- Mutational falsetto and other functional voice disorders — voice therapy (direct and indirect techniques)
- ICD-10 covered diagnoses referenced in the policy: J38.00 - J38.02 (Paralysis of vocal cords and larynx)
- ICD-10 covered diagnoses referenced in the policy: J38.1 (Polyp of vocal cord and larynx)
- ICD-10 covered diagnoses referenced in the policy: J38.2 (Nodules of vocal cords)
1 Active Policy
AETNA-CPB-0646 — Voice Therapy
Related Codes
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