P22.0 — Respiratory distress syndrome of newborn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For anticoagulation alternatives (e.g., argatroban), documentation of indication for alternative anticoagulation (e.g., HIT or AT deficiency) and target monitoring strategy (aPTT/ACT targets).
- No documentation requirements are specified in this document chunk. The excerpt is a reference list and does not include required medical record, test result, or clinical documentation statements.
- When ECMO is requested as a bridge (to transplant or to durable mechanical circulatory support): documentation of intent (bridge to heart, liver, lung or heart-lung transplantation or to durable mechanical circulatory support) and short-term intent (hours to a few days) as appropriate.
- For neonates: documentation that the neonate meets all selection criteria — explicit recorded diagnosis from the policy list (e.g., congenital diaphragmatic hernia; hyaline membrane disease; meconium aspiration; persistent fetal circulation; possible cardiac anomaly; refractory neonatal septic shock; respiratory distress syndrome; uncontrollable air leak), documented gestational age (>= 34 weeks), documented birth weight (>= 2,000 grams), and documented age at time of ECMO (< 10 days, preferably < 7 days).
Key Coverage Criteria
- P29.30 - P29.38 Persistent fetal circulation
- Neonates: ECMO in neonates who meet all of the following criteria: Diagnosis of any of the following: Congenital diaphragmatic hernia; or Hyaline membrane disease; or Meconium aspiration; or Persistent fetal circulation; or Possible cardiac anomaly; or Refractory neonatal septic shock; or Respiratory distress syndrome; or Uncontrollable air leak; and Gestational age of at least 34 weeks; and Birth weight of 2,000 grams or greater; and Age less than 10 days (preferably less than 7 days).
- Children and adults: ECMO and extracorporeal life support (ECLS) for children and adults with any of the following diagnoses when the risk of death is very high despite optimal conventional therapy: Adult respiratory distress syndrome (ARDS); or As a short-term (i.e., hours to a few days) bridge to heart, liver, lung or heart-lung transplantation; or As a short-term bridge to durable mechanical circulatory support; or Following heart surgery to ease transition from cardiopulmonary bypass to vent [...]
- 33947 initiation, veno-arterial
- I47.20, I47.21, I47.29 Ventricular tachycardia
- I49.01 Ventricular fibrillation
4 Active Policies
AETNA-CPB-0339 — Pulse Oximetry and Capnography for Home Use
AETNA-CPB-0518 — Nitric Oxide, Inhalational (INO)
AETNA-CPB-0546 — Extracorporeal Membrane Oxygenation (ECMO)
ANTHEM-CG-MED-69 — CG-MED-69 Inhaled Nitric Oxide
Related Codes
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