P28.42 — Obstructive apnea of newborn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each echocardiography service requires a formal written report with interpretation retained in the record and copies of image documentation (paper or electronic) available for review.
- A complete study must include M-mode and/or 2D measurements of LV end-diastolic diameter, LV end-systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion, and a qualitative description of LV function, or valid substitutes such as LV volumes, ejection fraction, and mass.
- Doppler interrogation must state the modes used and provide both qualitative and quantitative information.
Key Coverage Criteria
- Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
- Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
- Repeat echocardiographic studies are covered to monitor changes in cardiac structure or function when there is a change in clinical status or when disease progression is suspected.
- Echocardiograms performed as part of the CAMZYOS REMS program are covered when billed with modifier KX and all REMS program requirements are met for patients with NYHA Class II–III obstructive hypertrophic cardiomyopathy (I42.1).
- TTE is indicated to assess cardiac effects of systemic hypertension, including detection of left ventricular hypertrophy to guide long-term antihypertensive therapy.
- TTE is indicated to evaluate ventricular function, cardiomyopathies, and heart failure when history, physical exam, or routine labs suggest or cannot exclude cardiac disease.
5 Active Policies
A56781 — Billing and Coding: Transthoracic Echocardiography (TTE)
J06
L33577 — Transthoracic Echocardiography (TTE)
J06
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
A57306 — Billing and Coding: Transthoracic Echocardiography (TTE)
L34338 — Transthoracic Echocardiography (TTE)
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