A9569 — Technetium tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Retain and provide copies of hard-copy output with analysis of all data (including bidirectional vascular flow or imaging when provided) in the patient record.
- Document clinical findings (e.g., signs/symptoms) and clinical decision rules (Wells score) supporting the medical necessity for the ultrasound.
- For outpatient non-active cancer patients with Wells score <2, include the positive D-dimer result in the record prior to performing ultrasound.
- For follow-up ultrasounds in patients on therapy, document the clinical change and rationale showing how change in thrombus burden will alter treatment.
Key Coverage Criteria
- Perform peripheral venous ultrasound to evaluate clinical signs or symptoms suggestive of acute or new-onset deep vein thrombosis (e.g., extremity swelling, tenderness, erythema).
- Perform venous ultrasound to investigate DVT as the source of a confirmed pulmonary embolism.
- Repeat or perform venous ultrasound for patients with known venous thrombosis who have a clinical change and where documented change in thrombus burden would alter management or therapy.
- Perform venous ultrasound to evaluate postthrombotic (postphlebitic) syndrome in patients with symptoms consistent with PTS (e.g., chronic leg pain, heaviness, swelling, itching, or leg ulcers).
- Perform venous ultrasound to evaluate suspected valvular incompetence in patients with symptomatic chronic venous insufficiency or symptomatic varicose veins when the result will confirm diagnosis prior to treatment.
- Perform venous ultrasound for post-procedural assessment following venous ablation to evaluate treatment outcome or complications.
7 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
L35007 — Vestibular and Audiologic Function Studies
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35451 — Peripheral Venous Ultrasound
J12
L35434 — Oximetry Services
Related Codes
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