P61.1 — Polycythemia neonatorum
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- General laboratory documentation: hematocrit (Hct), hemoglobin (Hgb), serum ferritin, serum iron studies and, where relevant, hepatic iron concentration (LIC) measurements; records of prior/concurrent therapies (e.g., testosterone therapy) and clinical signs/symptoms supporting the need for therapeutic phlebotomy
- Hematocrit and hemoglobin values as required by indication (examples in policy: Hct ≥55% for erythrocytosis of undetermined etiology; Hct ≥54% or Hb ≥180 g/L for individuals receiving testosterone therapy)
- Serum ferritin levels and iron indices for hemochromatosis: policy cites initiation thresholds 'men with serum ferritin levels of 300 ug/L or more and in women with serum ferritin levels of 200 ug/L or more' (Hemochromatosis Management Working Group) and treatment targets ('remove until ferritin 10 to 20 ug/L; maintenance ferritin ≤50 ug/L'); AASLD recommends target ferritin 50–100 µg/L and initiation of phlebotomy in non-HFE iron overload with elevated hepatic iron concentration
Key Coverage Criteria
- E29.1 (Testicular hypofunction)
- E80.1 (Porphyria cutanea tarda)
- D75.1 (Secondary polycythemia)
- Erythrocytosis of undetermined etiology where the hematocrit is 55 % or higher
- Hemochromatosis (including hereditary hemochromatosis)
- Individuals receiving testosterone therapy if hematocrit is greater than or equal to 54 % (or hemoglobin is greater than or equal to 180 g/L)
1 Active Policy
AETNA-CPB-0652 — Therapeutic Phlebotomy
Related Codes
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