E1399, Durable medical equipment, miscellaneous
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Documentation of clinical concern for symptomatic COVID-19 infection (e.g., symptoms consistent with COVID-19) when ordering molecular or antigen testing.
- Documentation of known or suspected exposure to SARS-CoV-2 when that is part of the indication for testing.
- Order must be placed and the test administered by a licensed or authorized healthcare provider (documentation of ordering provider and administration).
- For antibody (serology) testing: documentation of prior molecular or antigen test results that were non-diagnostic, and documentation that the antibody test result will be used to aid in diagnosis of a condition related to COVID-19 (e.g., clinical notes supporting suspicion of MIS or post-acute sequelae).
- When antibody testing is used to support diagnosis of MIS (MIS-A or MIS-C): clinical documentation consistent with MIS definitions (e.g., fever, multisystem involvement as listed in policy, hospitalization when applicable), laboratory evidence of inflammation (e.g., elevated CRP, ferritin, IL-6, ESR, procalcitonin), and evidence of current or recent SARS-CoV-2 infection by PCR, antigen, or serology as applicable (policy enumerates specific MIS laboratory and clinical criteria).
- For high-throughput molecular/antigen tests: documentation that the performing laboratory is CLIA-certified as high-complexity when claiming coverage for such testing.
Key Coverage Criteria
- Molecular or antigen in vitro diagnostic test for SARS-CoV-2 (COVID-19) infection when ALL of the following criteria are met: clinical concern for a symptomatic COVID-19 infection; individual with known or suspected exposure; ordered and administered by a licensed or authorized healthcare provider.
- Antibody (serology) test for SARS-CoV-2 antibodies when: results of a molecular or antigen test is non-diagnostic for COVID-19 AND the results of the antibody test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS], post-acute sequelae).
- Molecular/antigen tests (CPT/HCPCS listed in policy) billed with any diagnosis codes other than the specified non-covered screening/administrative codes are considered medically necessary when the above policy clinical criteria are met (policy notes 'All other codes').
- Antibody (serology) testing (CPT codes listed under Antibody Testing) is considered medically necessary for diagnoses M35.81 (Multisystem inflammatory syndrome) and U09.9 (Post COVID-19 condition, unspecified) when applicable clinical criteria are met.
- Replacement polycarbonate bottle for use with breast pump (HCPCS A4285).
- Replacement locking ring for breast pump (HCPCS A4286).
20 Active Policies
CIGNA-0557, COVID-19: In Vitro Diagnostic Testing
HUMANA-MEDICAL-SUPPLIES-EQUIPMENT-AND-APPLIANCES-DURABLE-MEDICAL-EQUIPMENT-OK-MEDICAID, Medical Supplies, Equipment and Appliances Durable Medical Equipment
ANTHEM-DME.00011, DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
ANTHEM-DME.00022, DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
ANTHEM-DME.00050, DME.00050 Remote Devices for Intermittent Monitoring of Intraocular Pressure
ANTHEM-DME.00048, DME.00048 Virtual Reality-Assisted Therapy Systems
ANTHEM-DME.00047, DME.00047 Rehabilitative Devices with Remote Monitoring
ANTHEM-DME.00044, DME.00044 Robotic Arm Assistive Devices
ANTHEM-MED.00138, MED.00138 Wearable Devices for Stress Relief and Management
ANTHEM-MED.00130, MED.00130 Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring
ANTHEM-MED.00134, MED.00134 Non-invasive Heart Failure and Arrhythmia Management and Monitoring Systems
ANTHEM-DME.00037, DME.00037 Cooling Devices and Combined Cooling/Heating Devices
ANTHEM-DME.00038, DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
ANTHEM-DME.00030, DME.00030 Altered Auditory Feedback Devices for Fluency Disorders
ANTHEM-CG-DME-30, CG-DME-30 Prothrombin Time Self-Monitoring Devices
ANTHEM-CG-DME-35, CG-DME-35 Electric Breast Pumps
ANTHEM-CG-DME-06, CG-DME-06 Compression Devices for Lymphedema
ANTHEM-CG-MED-28, CG-MED-28 Iontophoresis
ANTHEM-CG-DME-39, CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch Devices
MED201.014, Treatment of Hyperhydrosis
Related Codes
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