A9579, Injection, gadolinium-based magnetic resonance contrast agent, not otherwise
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Baseline audiometric testing performed prior to administration of the osmotic diuretic and repeat audiometric testing at approximately 3 hours post-ingestion (and sometimes at 1 and 2 hours) — documentation of timing of tests relative to diuretic administration is required.
- Record of the specific osmotic diuretic administered (glycerol, urea, or other), dose/route, and timing.
- Audiometric results documenting objective pre- and post-diuretic measures (pure-tone thresholds and speech discrimination) and whether test met positive criteria: either a 10 dB or more improvement at two or more frequencies (250–2,000 Hz) OR a 12% or greater improvement in speech discrimination scores.
- Clinical documentation justifying use of the dehydration test — specifically documentation demonstrating an 'atypical presentation' of Meniere's disease for which the dehydration test is being used to verify suspicion.
Key Coverage Criteria
- Dehydration testing with glycerol, urea, or other osmotic diuretics to verify the suspicion of endolymphatic hydrops (Meniere's disease) — medically necessary ONLY in members with atypical presentations of this disease.
- ICD-10 codes covered if selection criteria are met: H81.01-H81.09 (Meniere's disease).
- ICD-10 codes covered if selection criteria are met: H81.10-H81.13 (Benign paroxysmal vertigo).
- ICD-10 codes covered if selection criteria are met: H81.311-H81.399 (Other peripheral vertigo).
- ICD-10 codes covered if selection criteria are met: H81.41-H81.49 (Vertigo of central origin).
- ICD-10 codes covered if selection criteria are met: H83.01-H83.2X9 (Labyrinthitis).
2 Active Policies
AETNA-CPB-0571, Endolymphatic Hydrops (Meniere's Disease) Tests
EVICORE-HPLAN-CIGNA_MEDICARE-68F4526A04BF, 1199SEIU Radiology and Cardiology Claims Studio Code List - Effective 01/01/2026
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