G09, Sequelae of inflammatory diseases of central nervous system
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must include history and physical notes, laboratory results, and documentation of signs and symptoms that warrant the head/neck diagnostic imaging.
- Accurate HCPCS/CPT coding must be submitted to differentiate CT and MRI scans from other radiology services and to support coverage determinations.
- Documentation and supporting information must be available to Medicare upon request.
- Providers should check and apply Correct Coding Initiative (CCI) edits and applicable LCD guidance for correct code combinations before billing.
Key Coverage Criteria
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
- Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.
- Aetna considers intestinal transplantation medically necessary for persons who have clinical indicators of failed total parenteral nutrition (TPN) when the selection criteria below are met.
- Clinical Indicators of Failed TPN: Frequent episodes of severe dehydration despite intravenous fluid supplement in addition to TPN.
- Clinical Indicators of Failed TPN: Frequent line infection and sepsis. The development of 2 or more episodes of systemic sepsis due to line infection per year that requires hospitalization indicates failure of TPN therapy. A single episode of line-related fungemia, septic shock and/or acute respiratory distress syndrome are considered indicators of TPN failure.
- Clinical Indicators of Failed TPN: Impending or overt liver failure due to TPN-induced liver injury. The clinical signs include elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or hepatic fibrosis/cirrhosis.
4 Active Policies
AETNA-CPB-0353, Transcranial Doppler Ultrasonography
AETNA-CPB-0605, Intestinal Transplantation
AETNA-CPB-0703, Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow
A57204, Billing and Coding: MRI and CT Scans of the Head and Neck
Related Codes
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