J9165, Injection, diethylstilbestrol diphosphate, 250 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No specific documentation requirements or required medical records/test results are specified in this CPB. (The policy primarily identifies tests/procedures considered obsolete/not covered and lists associated CPT/HCPCS/ICD-10 codes.)
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses obsolete and unreliable tests and procedures and lists tests/procedures that Aetna considers experimental and investigational (i.e., not covered).
1 Active Policy
AETNA-CPB-0438, Obsolete and Unreliable Tests and Procedures
Related Codes
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