N85.A — Isthmocele
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- If used for an indication listed under the policy's 'experimental and investigational' section, there must be clear documentation supporting an evidentiary rationale — otherwise such use is considered investigational per policy (note: the policy states these uses are considered experimental/investigational and effectiveness has not been established).
- Documented clinical presentation of painful sensory neuropathy.
- Documented absence of a history of a disorder known to predispose to painful neuropathy (examples provided: diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy).
- Physical examination documentation demonstrating no findings consistent with large-fiber neuropathy (e.g., no reduced or absent muscle-stretch reflexes; no reduced proprioception and vibration sensation).
Key Coverage Criteria
- Measurement of intra-epidermal nerve fiber density (IENFD) by skin biopsy is medically necessary for the diagnosis of small-fiber neuropathy when ALL of the following criteria are met: Individual presents with painful sensory neuropathy; and There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); and Physical examination shows no evidence of findings consistent with large-f [...]
- ICD-10 code listed as covered if selection criteria are met: G60.8 — Other hereditary and idiopathic neuropathies
- 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)
2 Active Policies
AETNA-CPB-0754 — Chronic Pelvic Pain, Endometriosis, and Other Indications: Selected Treatments
AETNA-CPB-0774 — Nerve Fiber Density Measurement
Related Codes
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