P07.03 — Extremely low birth weight newborn, 750-999 grams
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- CPT coding: use CPT 93025 for microvolt T-wave alternans when selection/medical necessity criteria are met.
- Documentation that the patient is 'a person at risk of sudden cardiac death who meet[s] criteria for implantable cardioverter-defibrillator placement' (policy language indicating the clinical eligibility requirement).
- Documentation that MTWA testing was performed using the spectral analytic method (policy and CMS decision memorandum requirement: 'only covered when the spectral analytic method is used').
- Documentation that 'selection criteria are met' when billing CPT 93025 or the listed covered ICD-10 diagnoses (policy repeatedly states codes are 'covered if selection criteria are met').
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: I47.0 - I47.9 (Paroxysmal tachycardia) [note in policy: not covered for guiding anti-arrhythmic therapy].
- ICD-10 codes covered if selection criteria are met: I49.02 (Ventricular flutter) [note in policy: not covered for guiding anti-arrhythmic therapy].
- ICD-10 codes covered if selection criteria are met: I49.2 (Junctional premature depolarization).
- Aetna considers microvolt T-wave alternans (MTWA) diagnostic testing using the spectral analytic method medically necessary for the evaluation of persons at risk of sudden cardiac death who meet criteria for implantable cardioverter-defibrillator placement.
- CPT 93025 (Microvolt T-wave alternans for assessment of ventricular arrhythmias) is covered if selection criteria are met.
- ICD-10 codes covered if selection criteria are met: I42.0 - I42.2 (specific cardiomyopathies), I42.5, I42.8 - I42.9 (other and unspecified cardiomyopathies).
2 Active Policies
AMBETTER-CP.VP.26 — Extended Ophthalmoscopy
AETNA-CPB-0579 — T-Wave Alternans
Related Codes
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