N02.A — Recurrent and persistent hematuria with C3 glomerulonephritis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Tonsillectomy is consideredmedically necessaryfor individuals 18 years of age and older who meet one or more of the criteria below:
- A history of recurrent acute throat infection with a frequency of at least:Three or more episodes in the previous 6 months;orFour or more episodes in the previous 12 months;andDocumentation in the medical record for each episode of sore throat which includes at least one of the following:Temperature greater than 38.3 °C (100.9 °F);orCervical adenopathy;orTonsillar exudate or erythema;orPositive test for Group A Ã-hemolytic streptococcus (GABHS);or
- Three or more episodes in the previous 6 months;or
- Four or more episodes in the previous 12 months;and
- Documentation in the medical record for each episode of sore throat which includes at least one of the following:Temperature greater than 38.3 °C (100.9 °F);orCervical adenopathy;orTonsillar exudate or erythema;orPositive test for Group A Ã-hemolytic streptococcus (GABHS);or
- Temperature greater than 38.3 °C (100.9 °F);or
2 Active Policies
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
ANTHEM-CG-SURG-51 — CG-SURG-51 Outpatient Cystourethroscopy
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