J2760 — Injection, phentolamine mesylate, up to 5 mg
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
- Clinical documentation must support a clinical diagnosis of CRPS using the Budapest Criteria: continuing pain disproportionate to any inciting event; at least one reported symptom in each of the four categories (sensory, vasomotor, sudomotor/edema, motor/trophic); at least one sign at time of evaluation in two or more of these categories; and no other diagnosis that better explains the signs and symptoms.
- History and physical exam records documenting the specific symptoms and signs required by the Budapest Criteria (sensory: hyperesthesia/allodynia; vasomotor: temperature asymmetry/skin color changes; sudomotor/oedema: edema/sweating changes; motor/trophic: decreased ROM, motor dysfunction, trophic changes).
- If imaging or laboratory tests are used to exclude alternative diagnoses, documentation should show rationale for the test and how results influenced management; documentation should also show that the provider understands that listed experimental/investigational tests are not established diagnostic tools for CRPS.
Key Coverage Criteria
- Imaging or other studies may be used as additional/ supportive tools to establish the diagnosis in doubtful cases (clinical findings remain the gold standard).
- Diagnosis of complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is primarily a clinical diagnosis based on history and physical examination.
- The Budapest Criteria (Harden et al.) are the preferred diagnostic tool for adults and should be used to make the clinical diagnosis of CRPS.
- All individuals with suspected CRPS should undergo rapid diagnostic assessment by a clinician using clinical history and physical exam guided by the Budapest Criteria.
- Comprehensive history and physical examination for assessment of sexual dysfunction in males and females
- Pharmacologic screening for erectile dysfunction using intracavernosal injection (papaverine, phentolamine, or prostaglandin E1).
6 Active Policies
AETNA-CPB-0147 — Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD): Diagnosis
BCBSIL-MED201.030 — Sexual Dysfunctions, Assessment and Treatment
BCBSMT-MED201.030 — Sexual Dysfunctions, Assessment and Treatment
BCBSNM-MED201.030 — Sexual Dysfunctions, Assessment and Treatment
BCBSOK-MED201.030 — Sexual Dysfunctions, Assessment and Treatment
Related Codes
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