J2590 — Injection, oxytocin, up to 10 units
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified to justify ASD evaluation and diagnosis.
- Evidence that the evaluation was performed by an appropriate certified/licensed health care professional (e.g., board certified behavioral analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, speech-language pathologist, audiologist).
- Use of standardized parent interviews and direct, structured behavioral observation as part of diagnostic assessment; documentation of instruments used when applicable (e.g., Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule-2 (ADOS-2), Childhood Autism Rating Scale-2 (CARS-2), Asperger Syndrome Diagnostic Scale).
Key Coverage Criteria
- Comparative genomic hybridization (CGH) when medical necessity criteria are met (see CPB 0787).
- Complete medical evaluation including medical history and physical examination, including neurologic evaluation.
- Parent and/or child interview (including siblings of children with autism).
- Quantitative plasma amino acid assays to detect phenylketonuria.
- Selective metabolic testing when the child exhibits any of the following: cyclic vomiting, recurrent vomiting and dehydration; early seizure; lethargy; hearing impairment; hypotonia; visual impairment; unusual odor; dysmorphic or coarse features; evidence of mental retardation or mental retardation cannot be ruled out; or occurrence/adequacy of newborn screening for a birth defect is questionable.
- Genetic counseling for parents of a child with autism.
2 Active Policies
AETNA-CPB-0406 — Tinnitus Treatments
AETNA-CPB-0648 — Autism Spectrum Disorders
Related Codes
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