J3105 — Injection, terbutaline sulfate, up to 1 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
- Documentation of the diagnosis of preterm labor (e.g., ICD-10 O60.02 - O60.03) and gestational age (after 22 weeks but before 37 weeks) when applicable.
- Clinical documentation that the pregnant woman is at risk of preterm delivery within 7 days (to support use of magnesium sulfate for short-term prolongation up to 48 hours).
- For fetal neuroprotection uses, documentation that delivery is anticipated to be early preterm (less than 32 weeks of gestation).
- Documentation of the specific clinical purpose for magnesium sulfate administration (e.g., to allow administration of antenatal corticosteroids, fetal neuroprotection, or prevention/treatment of eclampsia/preeclampsia).
Key Coverage Criteria
- Aetna considers magnesium sulfate injections medically necessary for short-term prolongation of pregnancy (up to 48 hours) in pregnant women who are at risk of preterm delivery within 7 days.
- Prevention and treatment of seizures in women with preeclampsia or eclampsia (as supported by ACOG/SMFM Committee Opinion on magnesium sulfate use in obstetrics).
- Fetal neuroprotection before anticipated early preterm (less than 32 weeks of gestation) delivery (as supported by ACOG/SMFM Committee Opinion on magnesium sulfate use in obstetrics).
- Short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal corticosteroids in pregnant women who are at risk of preterm delivery within 7 days (as supported by ACOG/SMFM Committee Opinion on magnesium sulfate use in obstetrics).
- Covered diagnosis codes (ICD-10) when selection criteria are met: O60.02 - O60.03 (Preterm labor without delivery [after 22 weeks but before 37 weeks]).
1 Active Policy
AETNA-CPB-0468 — Magnesium Sulfate Injections and Terbutaline Pump for Preterm Labor
Related Codes
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