P91.829 — Neonatal cerebral infarction, unspecified side
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation that the test is being ordered for one of the medically necessary indications specified by policy (e.g., borderline vitamin B12 deficiency where results will impact management; idiopathic or recurrent VTE; CRVO meeting the stated criteria; evaluation for homocystinuria due to CBS deficiency).
- For assessment of borderline vitamin B12 deficiency: documentation that results will impact the member's management (reference to CPB 0536 - Vitamin B-12 Therapy).
- For central retinal vein occlusion (CRVO): documentation of age (<56 years), absence of strong arteriosclerotic risk factors, and/or personal history of previous thrombosis or family history of thrombosis when ordering homocysteine testing for CRVO evaluation.
- For newborn screening of homocystinuria: documentation confirming hyper-methioninemia (homocysteine measurement only performed when hyper-methioninemia has been confirmed).
Key Coverage Criteria
- Assessment of idiopathic venous thrombo-embolism, recurrent venous thrombo-embolism, thrombosis occurring at a young age (i.e., less than 45 years of age), or thrombosis at an unusual site.
- CPT code 83090 (Homocysteine) — covered if selection criteria are met.
- ICD-10: D51.0 - D51.9 (Vitamin B12 deficiency anemia) — covered when selection criteria are met.
- ICD-10: D81.818 (Other biotin-dependent carboxylase deficiency) — covered when selection criteria are met.
- ICD-10: D81.819 (Biotin-dependent carboxylase deficiency, unspecified) — covered when selection criteria are met.
- ICD-10: E53.8 (Deficiency of other specified B group vitamins) — covered when selection criteria are met.
1 Active Policy
AETNA-CPB-0763 — Homocysteine Testing
Related Codes
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