T0572
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Class I: No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
- Class II: Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
- Class III: Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest.
- Class IV: Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients
Key Coverage Criteria
- Symptomatic Chronotropic Incompetence
- Indications for Asymptomatic Patients
- Prior to Planned Catheter Ablation
- Persistent Second Degree AV Block
- Sinus node dysfunction (CRID-8.2)
- Syncope (CRID-8.3)
1 Active Policy
EVICORE-CRID_FINAL — Cardiac Rhythm Implantable Devices (CRID) Guidelines
Related Codes
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