J7658 — Isoproterenol hcl, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, per milligram
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 supporting 'recurrent unexplained syncope' and that history and physical examination are inconclusive.
- Documentation of 'negative non-invasive tests of cardiac structure and function' (e.g., ECG, echocardiogram, other non-invasive cardiac studies) prior to tilt table testing for syncope evaluation.
- Clinical documentation supporting suspicion of POTS (symptoms such as light-headedness, visual blurring, palpitations and weakness on assuming an upright posture; and that tilt table testing is being performed as part of the diagnostic workup for suspected POTS).
- If pharmacologic provocative agents (e.g., isoproterenol) are used, documentation of the indication for pharmacologic provocation and agent/dose/administration.
Key Coverage Criteria
- Tilt table testing, alone or in combination with administration of provocative agents (e.g., isoproterenol), medically necessary for the following indications when criteria are met:
- For the evaluation of members with recurrent unexplained syncope who have an inconclusive history and physical examination, as well as negative non-invasive tests of cardiac structure and function;
- As part of a diagnostic workup for individual with suspected postural orthostatic tachycardia syndrome (POTS).
- CPT code covered if selection criteria are met: 93660 - Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention
- HCPCS codes covered if selection criteria are met: J7657, J7658, J7659, J7660 (isoproterenol formulations) — when selection criteria are met
- ICD-10 codes covered if selection criteria are met: I49.5 (Sick sinus syndrome); I49.8 (Other specified cardiac arrhythmias [postural orthostatic tachycardia syndrome]); R00.0 (Tachycardia, unspecified [postural orthostatic tachycardia syndrome]); R55 (Syncope and collapse)
1 Active Policy
AETNA-CPB-0299 — Tilt Table Testing
Related Codes
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