Q0139, Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- MRI is employed only when ultrasonography is not feasible or when ultrasonographic findings are not diagnostic (VSD evaluation).
- For transplant rejection pilot studies: biopsies were graded according to the International Society for Heart Lung Transplant system for cellular rejection with immunohistochemistry for humoral rejection — (implying biopsy correlation is used in study settings).
- Documentation that prior echocardiogram (including TTE/TEE as applicable) was inconclusive or expected to be nondiagnostic when MRI is requested for cardiac function, morphology, or valvular disease
- For atrial fibrillation when MRI is used to detect LAA thrombus: documentation that echocardiogram was inconclusive (if applicable) and clinical indication for MRI
Key Coverage Criteria
- B58.81 Toxoplasma myocarditis
- C34.00 - C38.8 Malignant neoplasm of bronchus and lung, thymus, heart, mediastium and pleura
- C45.0 C45.2 Mesothelioma of pleura and pericardium
- C47.3, C49.3 Malignant neoplasm of peripheral nerves of thorax and connective and soft tissue of thorax
- I70.201 - I70.799; I70.92 Atherosclerosis
- I71.00 - I71.9 Aortic aneurysm and dissection
4 Active Policies
UHC-POL-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
AETNA-CPB-0520, Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI
UMR-POL-UMR-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
SUREST-POL-SUREST-iv-iron-replacement-therapy, Intravenous Iron Replacement Therapy (Feraheme, Injectafer, & Monoferric)
Related Codes
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