B00.89 — Other herpesviral infection
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).
- Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
- When billing, providers must use the most appropriate codes as of the effective date of the submission.
- Each coverage request should be reviewed on its own merits; medical directors may exercise clinical judgment and determinations require consideration of the terms of the applicable benefit plan, applicable laws/regulations, relevant collateral source materials including Coverage Policies, and the specific facts of the situation.
Key Coverage Criteria
- Flow cytometry is considered medically necessary for the evaluation of any of the following: Hematopoietic/hematologic cancers; Immunodeficiency disorders, including human immunodeficiency virus (HIV) and acquired immunodeficiency virus syndrome (AIDS); Paroxysmal nocturnal hemoglobinuria; Gestational trophoblastic disease; Transplantation.
- Diagnosis and/or evaluation of hematopoietic cancers, including lymphomas and leukemia, plasma cell neoplasms, myelodysplastic syndromes, myeloproliferative neoplasms, and certain anemias (as described in General Background).
- Monitoring lymphocyte populations (e.g., T-cells, NK cells), including CD4 and CD8 counts and CD4/CD8 ratio for management of HIV disease (eligibility for antiretroviral therapy, monitoring immune restoration, guiding treatment against opportunistic infections).
- Detection of minimal residual disease and detection of antigens used as therapeutic drug targets for cancer therapy (hematologic malignancies).
- Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) — flow cytometry is considered the gold standard for identifying peripheral blood cells missing GPI-anchored proteins.
- Assessment of DNA ploidy in gestational trophoblastic disease, including molar pregnancies.
1 Active Policy
CIGNA-0538 — Flow Cytometry - (0538)
Related Codes
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