N83.299 — Other ovarian cyst, unspecified side
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For Morton's neuroma: documentation that conservative treatments (including orthotic use) and corticosteroid injections have failed.
- For symptomatic renal cysts: documentation that the cyst is symptomatic (pain, hematuria, and/or hypertension) and measures 3 to 20 cm in size.
- For active esophageal variceal hemorrhage: documentation that the person failed to adequately respond to or cannot undergo endovenous ligation (EVL).
- For pediatric rectal prolapse: patient age consistent with pediatric population and diagnosis (ICD-10 K62.3).
Key Coverage Criteria
- Percutaneous aspiration with sclerotherapy (PAS) for symptomatic simple hepatic cysts (SHC)
- Intravesical dextrose prolotherapy for bladder pain syndrome / interstitial cystitis (IC/BPS)
- Percutaneous aspiration and sclerotherapy (AS/PAS) for symptomatic simple renal cysts (SRCs)
- Endoscopic injection sclerotherapy (EIS) as a treatment option for acute esophageal variceal bleeding in cirrhosis (alternative to endoscopic variceal ligation)
- Active esophageal variceal hemorrhage in persons who failed to adequately respond to or cannot undergo endovenous ligation (EVL)
- Aneurysmal bone cyst
3 Active Policies
AETNA-CPB-0207 — Prolotherapy and Sclerotherapy
AETNA-CPB-0530 — Transvaginal Ultrasonography
ANTHEM-CG-MED-84 — CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting
Related Codes
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