G56.00 — Carpal tunnel syndrome, unspecified upper limb
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims and documentation requirements for CPNB are governed by and must follow the Local Coverage Determination L37641 referenced by this guideline.
- Pre-operative mammogram for women aged 40 years and older (the only criterion identified by Nguyen et al as supportable; cited in text).
- For adolescents: documentation that breast growth has ceased and that breast size has been stable for at least 12 months prior to reduction mammaplasty (ASPS/ACOG guidance cited).
- Counseling documentation: counseling regarding risks associated with obesity and smoking and recommendation to lose weight and stop smoking prior to elective reduction mammoplasty (studies cite increased complications with smoking and obesity).
Key Coverage Criteria
- No specific coverage indications are stated in this billing/coding guideline; refer to Local Coverage Determination L37641 for covered indications for continuous peripheral nerve blocks (CPNB).
- C. Breast asymmetry: referral to CPB 0185 (Breast Reconstructive Surgery) for medical necessity criteria for surgery to correct breast asymmetry.
- Applicable ICD-10 diagnoses listed as covered when selection criteria are met: G56.00–G56.93 (mononeuropathies of upper limb / upper extremity paresthesia); I96 (gangrene / tissue necrosis); L98.491–L98.494 (non-pressure chronic ulcer of skin of other sites); N62 (hypertrophy of breast); N64.89 (other specified disorders of breast / soft tissue infection).
- CPT code listed as covered if selection criteria are met: 19318 (reduction mammaplasty).
- Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin.
- Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders.
20 Active Policies
AETNA-CPB-0017 — Breast Reduction Surgery and Gynecomastia Surgery
AETNA-CPB-0029 — Thermography
AETNA-CPB-0100 — Cryoablation
AETNA-CPB-0107 — Chiropractic Services
AETNA-CPB-0009 — Orthopedic Casts, Braces and Splints
Related Codes
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