Q62.31 — Congenital ureterocele, orthotopic
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
- CT scans must be performed on CT equipment models that are FDA-known and in full market release phase.
- For thoraco-amniotic shunt (TAS) and pleuro-amniotic shunt: ultrasound documentation of fetal pleural effusion/macro-cystic lung lesion and hydrops, gestational age, pre-procedure counseling, and post-procedure imaging showing reduction in effusion/lesion size and hydrops resolution where applicable.
- For fetal cardiac interventions (e.g., FAV): detailed fetal echocardiography demonstrating critical aortic stenosis with echocardiographic predictors of evolving HLHS (e.g., valve z-scores, ventricular dimensions, pressure gradients), gestational age (mid-gestation candidates), multidisciplinary counseling documentation, and plan for postnatal management and follow-up; documentation that center has required expertise and registry/quality reporting where applicable.
Key Coverage Criteria
- CT abdomen is medically necessary to evaluate abdominal pain.
- CT abdomen is medically necessary to evaluate known or suspected abdominal masses or fluid collections.
- CT abdomen is medically necessary for evaluation of primary or metastatic malignancies in the abdomen.
- CT abdomen is medically necessary to evaluate abdominal inflammatory processes.
- CT abdomen is medically necessary to evaluate abnormalities of abdominal vascular structures.
- CT abdomen is medically necessary to evaluate abdominal trauma.
3 Active Policies
AETNA-CPB-0449 — Fetal Surgery In Utero
A56421 — Billing and Coding: CT of the Abdomen and Pelvis
L34415 — CT of the Abdomen and Pelvis
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