Z51.5 — Encounter for palliative care
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- If CPT codes 61720 or 61735 are billed, clinical documentation should support the selection criteria referenced by the CPB (i.e., the indication of terminal cancer pain as a last resort).
- No explicit documentation requirements section provided in policy.
- Implied documentation requirements: documentation that the procedure is a 'last resort' for terminal cancer pain (i.e., record of terminal cancer diagnosis and that other appropriate pain treatments have been tried and failed), and that care is provided in the context of palliative/terminal care (ICD-10 Z51.5).
- Policy notes and cited consensus/guidelines emphasize need for strict inclusion criteria, multidisciplinary evaluation, documented refractoriness to standard therapies, and proper consent procedures (as described in background and references), although these are not enumerated as specific required documentation items in the CPB.
Key Coverage Criteria
- Stereotactic cingulotomy medically necessary when used as a last resort to provide pain relief for members with terminal cancer pain.
- ICD-10 G89.3 — Neoplasm related pain (acute) (chronic) [used as a last resort to provide pain relief for members with terminal cancer pain]
- ICD-10 Z51.5 — Encounter for palliative care [terminal care]
- CPT codes 61720 and 61735 covered if selection criteria are met (creation of lesion by stereotactic method, see CPT table).
- Differentiation of cardiogenic from pulmonary causes of acute dyspnea.
- Cardiac monitoring using electrical bioimpedance devices is medically necessary when medical history, physical examination, and standard assessment tools provide insufficient information and the treating physician has determined that thoracic electrical bioimpedance hemodynamic data are necessary for appropriate management.
2 Active Policies
AETNA-CPB-0288 — Stereotactic Cingulotomy and Capsulotomy
AETNA-CPB-0472 — Electrical Bioimpedance for Cardiac Output Monitoring and Other Selected Indications
Related Codes
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