J2805, Injection, sincalide, 5 micrograms
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
- No explicit documentation requirements are stated in the policy
- Policy references clinical data elements commonly used in interpretation (e.g., gallbladder ejection fraction values such as <40% or <35%, reproduction of biliary pain during CCK-CS, prior ultrasonography showing cholelithiasis), but the policy does not mandate specific documentation or test result thresholds as coverage preconditions
Key Coverage Criteria
- CPT codes covered if selection criteria are met: 78226 (Hepatobiliary system imaging, including gallbladder when present)
- ICD-10 codes covered if selection criteria are met: K82.A1 - K82.A2 (Disorders of gallbladder in diseases classified elsewhere)
- ICD-10 codes covered if selection criteria are met: K83.1 (Obstruction of bile duct [common])
- ICD-10 codes covered if selection criteria are met: K83.4 (Spasm of sphincter of Oddi)
- CPT codes covered if selection criteria are met: 78227 (with pharmacologic intervention, including quantitative measurement(s) when performed)
- HCPCS codes covered if selection criteria are met: J2805 (Injection, sincalide, 5mcg)
1 Active Policy
AETNA-CPB-0266, Cholecystokinin Cholescintigraphy
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