P07.37 — Preterm newborn, gestational age 34 completed weeks
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Detailed drawing(s) of views of the patient's retina(s) and any defects documented in the medical record.
- Record of the examination method used (direct vs indirect; contact lens, H‑ruby lens, or 90‑diopter lens), which eye(s) were examined, and identity/licensure of the performing eye care provider.
- Detailed retinal drawing (disc, macula or periphery) accompanied by an interpretation and report.
- Drawing must be anatomically specific to the patient, clearly labeled, and of sufficient size (no less than 3–4 inches in diameter).
Key Coverage Criteria
- Therapeutic use of iNO is consideredmedically necessarywhen either criterion AorB is met:
- Inhaled nitric oxide is consideredmedically necessaryas a component of the treatment of hypoxic respiratory failure (see definition) in neonates when the following criteria are met:The neonate was born at 34 or more weeks of gestation;andConventional therapies have failed;andNeonate does not have a congenital diaphragmatic hernia;or
- The neonate was born at 34 or more weeks of gestation;and
- Conventional therapies have failed;and
- Neonate does not have a congenital diaphragmatic hernia;or
- Inhaled nitric oxide is consideredmedically necessaryin the perioperative management of congenital heart disease when all the following criteria (1, 2 and 3) are met:The treated individual is an infant age 1 year (365 days) or less;andThere is preserved left ventricular function;andAdministered ineitherof the following clinical scenarios (a or b):As a prophylactic therapy when all the criteria (i, ii,andiii) are met;andInitiated ateitherof the following times:During surgical repair;orImmediately [...]
2 Active Policies
AMBETTER-CP.VP.26 — Extended Ophthalmoscopy
ANTHEM-CG-MED-69 — CG-MED-69 Inhaled Nitric Oxide
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