N39.9 — Disorder of urinary system, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in the CPB. (The document does not list explicit medical record, test result, or clinical documentation requirements for coverage or for investigational determinations.)
- Avian influenza A virus (H5N1): documentation of symptoms consistent with Avian influenza A virus and history of travel to or contact with persons or birds from a country with documented H5N1 avian influenza infections within 10 days of symptom onset.
- Cerebrospinal fluid (CSF) pathogen panel: Member has clinical findings consistent with a central nervous system (CNS) infection (e.g., meningitis, encephalitis); and viral etiology is suspected or the CSF culture is inconclusive for pathogen etiology (i.e., viral, bacterial, fungal).
- Coronavirus COVID-19 respiratory panel (up to 5 respiratory pathogens): Member has signs and symptoms of COVID-19 and test will be used to guide therapy.
Key Coverage Criteria
- Endometriosis
- None explicitly listed as covered in this CPB. The policy identifies the following procedures as experimental and investigational (i.e., effectiveness not established and thus not supported by this policy): dorsal root ganglion stimulation; hypogastric plexus neurolysis for the treatment of chronic pelvic pain associated with endometriosis; peritoneal excision (stripping) for the treatment of endometriosis; uterine nerve ablation (UNA), laparoscopic uterine nerve ablation (LUNA) and presacral n [...]
- Other indications related to pelvic pain addressed by selected treatments (policy scope: selected treatments for chronic pelvic pain, endometriosis, and other indications)
- Acanthamoeba in corneal ulceration
- Actinomyces, for identification of actinomyces species in tissue specimens
- Adenovirus, to diagnose adenovirus myocarditis, and to diagnose adenovirus infection in immunocompromised hosts, including transplant recipients
4 Active Policies
AETNA-CPB-0530 — Transvaginal Ultrasonography
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
ANTHEM-CG-LAB-24 — CG-LAB-24 Outpatient Urine Culture
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.