L8699, Prosthetic implant, not otherwise specified
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Use of intra-operative/intra-wound vancomycin powder: document dosing/administration, indication, baseline infection risk factors, and post-operative monitoring for wound complications, AKI, ototoxicity (authors reported no statistical difference but monitored these endpoints).
- When using TXA: documentation of procedure type (primary THA), route and dosing of TXA (intravenous, topical, or combined), and exclusion/consideration if revision THA or hip fracture surgery (VHA: evidence lacking in revisions/hip fracture).
- Robotic or navigation-assisted THA: pre-operative target angles, intra-operative navigation records (intra-operative cup angles using navigation records), and post-operative imaging to verify cup orientation (post-operative CT data or radiographs) as used in the cited studies (e.g., HipAlign intra-op records vs post-op CT comparisons).
Key Coverage Criteria
- Progressive or substantial periprosthetic bone loss confirmed by imaging;
- Outside-in arthroscopic psoas release for anterior iliopsoas impingement after primary total hip arthroplasty
- Fracture or mechanical failure of 1 or more components of the prosthesis confirmed by imaging;
- Confirmed periprosthetic infection confirmed by gram stain and culture;
- Displaced periprosthetic fracture confirmed by imaging;
- Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction;
12 Active Policies
CIGNA-0446, Metatarsophalangeal Joint Replacement
ANTHEM-MP-A050276, ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
ANTHEM-MP-E001585, TRANS.00038 Thymus Tissue Transplantation
ANTHEM-SURG.00132, SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
ANTHEM-CG-SURG-81, CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
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