82607 aetna policy. Policy Scope of Policy.

82607 aetna policy Qualitative Polymerase Chain Reaction (PCR) Testing. Text ANHC today. e. Pre-operative staging of newly diagnosed members with biopsy-proven prostate cancer that is thought to be clinically localized after standard diagnostic evaluation, This Clinical Policy Bulletin addresses serologic markers and pharmacogenomic and metabolic assessment of thiopurine therapy for inflammatory bowel disease. Aetna considers extended ophthalmoscopy with a detailed retinal drawing for evaluation of the posterior portion of the eye following routine ophthalmoscopy medically necessary for any of the following indications:. This Clinical Policy Bulletin addresses intranasal radiofrequency ablation. 18 mg implant) for the treatment of chronic non-infectious uveitis (including This Clinical Policy Bulletin addresses coronary artery brachytherapy and other adjuncts to coronary interventions. This Clinical Policy Bulletin addresses gout for commercial medical plans. Coverage Aetna considers the following medically necessary when criteria are met: The above policy is based on the following references: Abdalla G, Fawzi Matuk R, Venugopal V, et al. 1 and 281. This Clinical Policy Bulletin addresses colonoscopy and colorectal cancer screening. Aetna considers body surface potential mapping (also known as body surface mapping) experimental, investigational, or unproven for the following indications (not an all-inclusive list) because the effectiveness of this approach has not been 10/2022 • Reformatted and reorganized policy, transferred content to new template with new Reimbursement Policy Number . Aetna considers FDA approved or cleared mobile apps for contraception based on fertility awareness (e. Aetna considers cognitive rehabilitation as adjunctive treatment of cognitive deficits (e. This Clinical Policy Bulletin addresses invasive procedures for headaches. years’ experience years’ years’ arrange Operation Policy Scope of Policy. , XTRAC, PhotoMedex, Radnor, PA; EX-308, Ra Medical Systems, Inc. Curr Opin Policy Scope of Policy. This Coverage Policy addresses measurement of plasma brain natriuretic peptide (BNP) or NT-proBNP in an outpatient setting. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. See section below on therapeutic shoes as integral Policy Scope of Policy. Aetna considers transient elastography (e. This Clinical Policy Bulletin addresses fibroid treatment. Ready to explore Medicare plans near you? Enter your ZIP code to find a plan that’s right for you. Aetna considers pneumococcal conjugate vaccines (PCV13, PCV15, PCV20, PCV21) and pneumococcal polysaccharide vaccine (PPSV23) medically necessary according to the recommendations of the Centers for Disease Control and Prevention’s (CDC) Advisory These laboratory procedure codes may not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. g. ZIP CODE. This Clinical Policy Bulletin addresses human papillomavirus (HPV) vaccine. FDA-approved implantable cardioverter-defibrillators (thoracotomy and non-thoracotomy systems) for any of the following groups of Policy Scope of Policy. Note: Requires Precertification:. This Clinical Policy Bulletin addresses signal-averaged electrocardiography (SAECG) and artificial intelligence algorithmic electrocardiograms for detection of cardiovascular-related diseases. This Clinical Policy Bulletin addresses autism spectrum disorders. The most up to date and comprehensive information about our standard coverage policies are available on CignaforHCP, without logging in, for your convenience. Kidney Transplantation. 3 Other amnesia R53. JL Home Policy Scope of Policy. This is determined by the state in which your performing laboratory resides and where your testing is commonly performed. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not The following Coverage Policy applies to health benefit plans administered by Cigna Companies. This Clinical Policy Bulletin addresses selected treatments for diabetic neuropathy. This Clinical Policy Bulletin addresses ultrasound for pregnancy. Note: Requires Precertification: Precertification of nivolumab (Opdivo) and nivolumab and relatlimab-rmbw (Opdualag) is required of all Aetna participating providers and members in Background. Local Coverage documents maintained in the MCD include: Start a Vitamin B-12 (82607) and folate (82746) can be tested up to four times per year for malabsorption syndromes (K90. Aetna considers human papillomavirus (HPV) 9-valent vaccine (Gardasil 9) a medically necessary preventive service for persons age 9 to 45 years. This Clinical Policy Bulletin addresses cardiac catheter ablation and radio-ablation. These are developed and published by CMS and apply to all states. , Micra Transcatheter Pacing System, Aveir Transcatheter Pacing System) medically necessary when both of the following criteria are met:. The full text of the guideline for Vit. Aetna considers RFVTR of turbinates for Policy Scope of Policy. This Clinical Policy Bulletin addresses non-invasive tests for hepatic fibrosis. This Clinical Policy Bulletin addresses optic nerve and retinal imaging methods. These codes will only be considered for separate reimbursement if they are the only service billed for a date of service or if they are billed ONLY coverage policy for diagnostic laboratory test(s) is a document stating CMS’s policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening. A national review team This Clinical Policy Bulletin addresses Vitamin D assay. The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. Routine Screening. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT code 82607. Aetna does not provide health care services and, therefore, cannot guarantee any results or These laboratory procedure codes may not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. 59 mg implant) and Yutiq (fluocinolone acetonide intravitreal 0. Aetna considers the following medically necessary: Endometrial biopsy (sampling) for histological tissue examination in the diagnostic evaluation of abnormal uterine bleeding in women suspected of having endometrial hyperplasia or Aetna considers measurement of plasma brain natriuretic peptide (BNP) medically necessary for the following indications: This policy is based in part upon the 2017 ACC/AHA/HFSA Focused Update of the ACCF/AHA 2013 Guideline for the Management of Heart Failure. This Clinical Policy Bulletin addresses hepatitis screening. Policy Scope of Policy. Aetna considers autonomic testing such as quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, and thermoregulatory sweat test (TST) medically necessary for use as a diagnostic tool for any of the following conditions/disorders: Policy Scope of Policy. , calcium hydroxylapatite (Renu)) for members with unilateral vocal cord paralysis using agents that are cleared by the Food and Drug Administration (FDA) for this indication; Note: This procedure has been shown to improve vocal quality and prevent recurrent aspiration pneumonia in Policy Scope of Policy. Aetna considers a Food and Drug Administration (FDA)-approved ventricular assist device (VAD) medically necessary for any of the following FDA-approved indications:. Aetna considers the following interventions experimental, investigational, or unproven for the following headache types because the effectiveness of these approaches has not been established (not an all-inclusive list): Policy Limitations and Exclusions. This Clinical Policy Bulletin addresses nebulizers. Aetna considers FDA-approved leadless cardiac pacemakers (e. , Prometheus TPMT Genetics, Prometheus TPMT Enzyme) prior to initiation of 6 Aetna Medicaid provides care management services to hundreds of thousands of high-cost, high-need Medicaid members. Clin Radiol. This Clinical Policy Bulletin addresses dysphagia therapy. Precertification of intravenous immunoglobulins (IVIG) [Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex Policy Scope of Policy. Aetna considers antibody tests medically necessary for the diagnosis and treatment of paraneoplastic neurologic disorders when all of the following are met: The member displays clinical features of the paraneoplastic neurologic disease in question, Policy Scope of Policy. This Clinical Policy Bulletin addresses coblation. Aetna considers the following interventions medically necessary when the following criteria are met: Implantable Cardioverter-Defibrillators. , The Policy Bulletins on this website were developed to allow Independence Blue Cross (Independence) to administer the provisions of members’ benefits plans and neither constitutes nor substitutes for medical advice. Medically Necessary Procedures. These codes will only be considered for separate reimbursement if they are the only service billed for a date of service or if they are billed ONLY Policy Scope of Policy. This Clinical Policy Bulletin addresses antibody tests for neurologic diseases. This Clinical Policy Bulletin addresses thoracoscopic sympathectomy. Laryngoscope. Aetna considers reconstructive breast surgery medically necessary: After a medically necessary mastectomy; or; A medically necessary lumpectomy that results in a significant deformity (i. This Clinical Policy Bulletin addresses denosumab (Prolia and Xgeva) for commercial medical plans. Simple bunionectomy (e. Cardiac resynchronization therapy for heart failure. Aetna considers biofeedback medically necessary for the following conditions: Cancer pain; Chronic constipation secondary to dyssynergic defecation as confirmed by anorectal manometry; Fecal incontinence ; Irritable bowel syndrome; Levator ani syndrome (also known as anorectal Policy Scope of Policy. Aetna considers the following established methods medically necessary for the treatment of vitiligo: Excimer laser (e. . , Carlsbad, CA) Narrow-band ultraviolet B (NB-UVB) Topical and oral psoralen Policy Scope of Policy. Alford RL, Arnos KS, Fox M, et al. C. This Clinical Policy Bulletin addresses breast biopsy procedures. As a result of the calendar year (CY) 2024 policy and technical changes to theMedicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly, changes have been made to the Blue Cross and Blue Shield of North Carolina Blue Medicare Advantage ℠ medical policies. This Clinical Policy Bulletin addresses dexamethasone ophthalmic implant (Ozurdex) and insert (Dextenza). Aetna considers the following procedures experimental, investigational, or unproven because the Policy Scope of Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Medically Necessary . Aetna considers the following procedures medically necessary: Hemodialysis or intermittent peritoneal dialysis for renal failure up to 3 times per week; Hemodialysis and intermittent peritoneal dialysis performed more than 3 times per week for Policy Scope of Policy. What is CPT 82607? CPT Aetna. This Clinical Policy Bulletin addresses shoulder arthroplasty and arthrodesis. This Clinical Policy Bulletin addresses biofeedback. , the Edwards Sapien 3, Edwards Sapien XT, Edwards Sapien Aetna considers the following interventions medically necessary: Injections of bulking agents (e. 25-OH Vitamin D-3 (82306) may be tested up to four times per year for Bone remodeling can be assessed by the measurement of surrogate markers of bone turnover in the blood or urine. Entering text into the form field will activate a list of options. Blunt injury to the eye or periorbital structures; or Policy Scope of Policy. 1, D51. Aetna considers ketamine (intramuscular, intranasal, intravenous, oral, or subcutaneous) experimental and investigational for the following indications because its clinical value and effectiveness for UnitedHealthcare community plan policies and guidelines for healthcare professionals. Similarly, assays for micronutrient testing for nutritional This Clinical Policy Bulletin addresses complementary and alternative medicine. Aetna considers automated ambulatory blood pressure monitoring medically necessary according to the selection criteria listed below, which are based, in part, on guidelines developed by the American College of Physicians. In these situations, we may use the delegated vendor’s guidelines to support medical necessity and other coverage determinations. Precertification of vedolizumab (Entyvio) is required of all Aetna participating providers and members in applicable plan designs. For Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Home oxygen therapy is only considered medically necessary if all of the following conditions are met:. Note: Requires Precertification: For precertification of products listed in this policy, call (866) 752-7021 or fax (888) 267-3277. Cigna Dental. For Medicare criteria, see Medicare Part B Criteria. Aetna considers radiofrequency ablation (open, laparoscopic (e. The member has a chronic Stage III or IV pressure ulcer (see Appendix below), Policy Scope of Policy. NCCI Procedure-to-Procedure Lookup. Aetna Better Health of Florida is not responsible or liable for non-Aetna Better Health content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. This Clinical Policy Bulletin addresses irinotecan liposome injection (Onivyde) for commercial medical plans. This Clinical Policy Bulletin addresses brachytherapy. This Clinical Policy Bulletin addresses treatment approaches for liver and other neoplasms. Aetna considers autologous chondrocyte implants medically necessary for repairing cartilage defects of the knee in members who have symptoms of disabling knee pain related to a full thickness, focal chondral defect with all of the following: Policy Scope of Policy. 2018; 7(10):304. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. The use of a small volume nebulizer and related compressor durable medical equipment (DME) for any of the following indications: To administer antibiotics (gentamicin, amikacin, or tobramycin, Policy Scope of Policy. This Clinical Policy Bulletin addresses ketamine for the treatment of depression and other selected indications. Experimental, Investigational, or Unproven. Aetna considers Coblation tonsillectomy medical necessary for the treatment of any of the following:. Title XVIII of the Social Security Act, Section 1833 (e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. In the absence of an institution’s selection criteria, Aetna considers kidney transplantation medically necessary This Clinical Policy Bulletin addresses nivolumab (Opdivo) and nivolumab and relatlimab-rmbw (Opdualag) for commercial medical plans. This Clinical Policy Bulletin addresses donanemab-azbt (Kisunla) for commercial medical plans. Aetna considers cardiac catheter ablation procedures Footnote1 * with electrophysiological studies medically necessary for any of the following arrhythmias: Atrial fibrillation (AF) In members with AF who meet any of Background. 1. Aetna does not provide health care services and, therefore, cannot guarantee any results or 10/2022 • Reformatted and reorganized policy, transferred content to new template with new Reimbursement Policy Number . Melanocytic nevi with Spitz differentiation: Diagnosis and management. 04. This Clinical Policy Bulletin addresses pneumococcal vaccines. Aetna considers the following as medically necessary exclusionary tests to be used for the evaluation of members suspected of having chronic fatigue syndrome (CFS) as recommended by the National Institutes of Health. Aetna considers autism spectrum disorder (ASD) evaluation and diagnosis medically necessary when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified and when the evaluation is performed POLICY NUMBER EFFECTIVE DATE: APPROVED BY RPC20220023 9/01/2022 EH CNY Plans 5/01/2020 ConnectiCare 1/2017 EH Commercial, Medicare and Medicaid Plans (excluding CNY) RPC (Reimbursement Policy Committee) Reimbursement Guideline Disclaimer: We have policies in place that reflect billing or claims payment processes unique to our health plans. 2, 281. Aetna considers the following surgical procedures medically necessary when criteria met: Surgical repair of severe pectus excavatum deformities that cause functional deficit when done for medical reasons in members who meet all of the following Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. ; ACMG Working Policy Scope of Policy. Aetna considers the following indications for speech therapy as medically necessary (unless otherwise specified): Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease when all of the following criteria are met: The member’s physician Policy Scope of Policy. , stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) medically necessary durable medical equipment (DME) for the treatment of intractable tremors as a Policy Scope of Policy. Aetna considers the following interventions medically necessary: Ozurdex (dexamethasone intravitreal implant) for the treatment of the following indications: Macular edema secondary to branch or central retinal vein occlusion; Policy Scope of Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. 9* Anemia, unspecified E53. Aetna considers the following interventions, unless otherwise specified below, medically necessary when the following criteria are met: Assessment of Neonatal Hyperbilirubinemia. Precertification of bevacizumab (Avastin), bevacizumab-maly (Alymsys), bevacizumab-tnjn (Avzivi), bevacizumab-awwb (Mvasi), bevacizumab-adcd Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses inclisiran (Leqvio) for commercial medical plans. Coverage Policy . Aetna considers radiofrequency volumetric tissue reduction (RFVTR, Somnoplasty) medically necessary for treatment of chronic nasal obstruction due to mucosal hypertrophy of the inferior turbinates. 135 (For Plan internal use only) Related Policies None Policy1 Commercial Members: Managed Care Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. (continued) 82306, 82652, 82379, 82607, 82746, 83090, 84207, 85385, 86352, 83698 Assays for Vitamins and Metabolic Function. Moda. Precertification of multiple sclerosis medications (Briumvi, Lemtrada, Ocrevus, Tyruko, Tysabri) are required of all Aetna participating providers and members in applicable Policy Scope of Policy. For Statement of Medical Necessity (SMN) precertification forms, see Aetna considers comparative genomic hybridization (CGH) medically necessary for the following indications: The above policy is based on the following references: Ahmadi N, Davison SP, Kauffman CL. , the Sonata System)) or transcatheter uterine artery embolization (UAE, e. This Clinical Policy Bulletin addresses Barrett's esophagus. Depression NCDs are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service. 83* Policy Scope of Policy. This Clinical Policy Bulletin addresses palivizumab (Synagis) for commercial medical plans. This Clinical Policy Bulletin addresses bevacizumab for non-ocular indications for commercial medical plans. 2010;120(12):2385-2390. for the following:. Precertification of ustekinumab (Stelara) administered by a healthcare provider is required of all Aetna participating providers and members in applicable plan designs. Aetna considers single photon emission computed tomography (SPECT) medically necessary for any of the following indications: Assessment of osteomyelitis, to distinguish bone from soft tissue infection; or; Detection of spondylolysis and Policy Scope of Policy. This Clinical Policy Bulletin addresses electromagnetic navigation-guided bronchoscopy. Aetna considers the following interventions medically necessary: Intramuscular or subcutaneous vitamin B-12 injections Explore the medical clinical policy bulletins that Aetna uses to decide which services and procedures we will cover. The diagnostic accuracy of magnetic resonance venography in the detection of deep venous thrombosis: A systematic review and meta-analysis. , intra-coronary radiation) in native coronary arteries or coronary artery bypass grafts as adjunctive treatment during a second Policy Scope of Policy. 62q: Pharmacy (08) Abatacept (Orencia®) for Injection for Intravenous Use: 488dec00-d5ea-416c-86b2 Policy Scope of Policy. This Clinical Policy Bulletin addresses ocular photo-screening. The treating physician has determined that the member has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses influenza vaccine. 2 Paresthesia of skin R41. Aetna considers the following qualitative polymerase chain reaction (PCR) testing medically necessary (not an all-inclusive list): Acanthamoeba in corneal ulceration; Actinomyces, for identification of New Policy • Autonomic Nerve Function Testing . Aetna considers ProstaScint scans medically necessary for either of the following indications:. Aetna considers ocular photo-screening medically necessary for screening of pre-verbal children up to 5 years of age, and children or adolescents who are non-cooperative or non-verbal (e. Aetna considers the following interventions medically necessary for treatment of dysphagia when criteria are met: Speech therapy for treatment of dysphagia, regardless of the presence of a communication disability, for members who meet the criteria set forth below: Policy Scope of Policy. Aetna considers the following interventions medically necessary: Retisert (fluocinolone acetonide intravitreal 0. Added Views of physicians practicing in relevant clinical areas affected by the policy. I'm a producer I'm a provider Shop Aetna Medicare plans. Medicaid. com CMS National Coverage Policy. This Clinical Policy Bulletin addresses erythropoiesis stimulating agents for commercial medical plans. Measurement of glucose-6-phosphate dehydrogenase (G6PD) levels for Policy Scope of Policy. Experimental and Investigational Aetna considers measurements of serum 25-hydroxyvitamin D experimental and investigational for It allows users to identify and view both National and Local Coverage documents that reside within the database. This Clinical Policy Bulletin addresses automated ambulatory blood pressure monitoring. This Clinical Policy Bulletin addresses breast reconstructive surgery. Aetna considers left atrial appendage closure (LAAC) devices medically necessary for non-valvular atrial fibrillation (NVAF) when the device has received U. This Clinical Policy Bulletin addresses neonatal hyperbilirubinemia. , the Edwards Sapien 3, Edwards Sapien XT, Edwards Sapien Policy Scope of Policy. 5. Available clinical information We may delegate utilization management of specific services. Aetna considers the following cerebral perfusion studies medically necessary when criteria are met: Cerebral computed tomography (CT) perfusion studies for diagnosis of acute ischemic stroke (within the first 24 hours), hemorrhagic stroke, subdural hemorrhage, and transient ischemic Policy Scope of Policy. This Clinical Policy Bulletin addresses body surface potential mapping. Aetna considers the following the following interventions experimental, investigational, or unproven because the effectiveness of these approaches has not been established: Motor cortex stimulation for the treatment of the Policy Search | Providers in DC, DE, MD, NJ & PA. Aetna considers the following tests medically necessary: TPMT gene mutation or TPMT phenotypic assays (e. Percutaneous Ethanol Injection. For precertification of Administrative Policy: A004 . Precertification of denosumab (Prolia, Xgeva) is required of all Aetna participating providers and members in applicable plan designs. Close . This Clinical Policy Bulletin addresses cognitive rehabilitation. Note: Requires Precertification: Precertification of inclisiran (Leqvio) is required of all Aetna participating providers and members in applicable plan designs. Treating providers are solely responsible for medical advice and treatment of members. Independence’s Policy Bulletins should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical 3 Pages - Cigna National Formulary Coverage - Policy:Vitamin B12 (Cyanocobalamin) Products Step Therapy Policy 4. Find medical, drug, and reimbursement policy information. Aetna considers the following indications medically necessary unless otherwise stated: Ultrasounds are considered not medically necessary if done solely to determine the fetal sex or to provide parents with a view and photograph of the Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses prescription digital therapeutics. This Clinical Policy Bulletin addresses vitiligo. Aetna considers irinotecan liposome injection (Onivyde) medically necessary as subsequent therapy for disease progression when Precertification of eculizumab (Soliris), eculizumab-aeeb (Bkemv), or eculizumab-aagh (Epysqli) is required of all Aetna participating providers and members in applicable plan designs. Note: Requires Precertification: Precertification of pegloticase (Krystexxa) is required of all Aetna participating providers and members in applicable plan designs. Aetna does not provide health care Policy Scope of Policy. For precertification of eculizumab or its biosimilar product, call (866) 752-7021 or fax (888) 267-3277. This Clinical Policy Bulletin addresses tumor scintigraphy. Note on Definition of Intensity Modulated Radiation Therapy (IMRT): For purposes of this policy, to qualify as IMRT, radiation therapy requires highly sophisticated treatment planning utilizing numerous beamlets to generate dosimtery in accordance with assigned dose requirements to the tumor and organs at risk. This Clinical Policy Bulletin addresses ustekinumab (Stelara) for commercial medical plans. Food and Drug Administration (FDA)-approved biventricular pacemakers The above policy is based on the following references: Abraham WT, Hayes DL. Aetna considers laboratory test panels experimental, investigational, or unproven if they include nonstandard tests that have no proven value. This Clinical Policy Bulletin addresses cerebral perfusion studies. , the Acessa System), or transcervical (e. Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome medically necessary for persons who fulfill all the following criteria:. These codes will only be considered for separate reimbursement if they are the only service billed for a date of service or if they are billed ONLY This Clinical Policy Bulletin addresses cardiac devices and procedures for occlusion of the left atrial appendage (LAAC). Precertification of palivizumab (Synagis) is required of all Aetna participating providers and members in applicable plan designs. Aetna considers any of the following as medically necessary when criteria are met: Transcatheter aortic valve implantation (TAVI) TAVI by means of a Food and Drug Administration (FDA)-approved aortic valve (e. Non-Cardiac Indications. This Clinical Policy Bulletin addresses extended ophthalmoscopy. Aetna considers the following medically necessary for evaluation of primary open-angle glaucoma: Computerized visual field examination; Gonioscopy; Measurement of optic nerve head and retinal nerve fiber layer. References to standard benefit plan language and coverage determinations do not apply to those clients. This Clinical Policy Bulletin addresses ventricular assist devices. Coverage Policies are intended to Policy Scope of Policy. This Clinical Policy Bulletin addresses kidney transplantation. Aetna considers electromagnetic navigation (EN)-guided bronchoscopy medically necessary for individuals with a peripheral pulmonary nodule that requires a pathologic diagnosis and is not accessible by standard bronchoscopy methods or Policy Scope of Policy. J Clin Med. ANHC now offers a new texting feature as another option to communicate with your care team! Patients can send TEXT ME to our main line, 907-743-7200, for various needs, like scheduling Medical Policy Overview & Search. Peri-tonsillar abscess; or Recurrent middle ear infection where tonsillar hypertrophy is believed to be an exacerbating factor; or Recurrent or chronic tonsillar infection; or Policy Scope of Policy. Aetna considers Gardasil 9 vaccination not medically necessary for persons who have completed a Anthem Blue Cross Coverage Determination Policy Cyanocobalamin (Vitamin B-12) Testing Page 1 of 3 Last Updated: February 26, 2023 ANTHEM BLUE CROSS LOCAL COVERAGE CLINICAL UM GUIDELINE #CG-LAB-19 Anthem Blue Cross has issued a coverage clinical UM guideline [CG-LAB-19] applicable to Cyanocobalamin (Vitamin B-12), CPT Code Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. This Clinical Policy Bulletin addresses dialysis. Medical policies are scientific documents that define the technologies, procedures, and treatments that are considered medically necessary, not medically necessary, and investigational link to investigational policy. , FibroScan) medically necessary for follow-up of primary sclerosing cholangitis, monitoring of liver function in Wilson's disease, and for distinguishing hepatic cirrhosis from non-cirrhosis in persons with hepatitis B Policy Scope of Policy. This Clinical Policy Bulletin addresses continuous passive motion (CPM) machines. Abraham WT. Premera Blue Cross Blue Shield. 0, D51. Note: This CPB does not address therapeutic drug monitoring, drug testing in the emergency room, or monitoring of persons prescribed drugs with abuse potential that are prescribed outside of a pain management program or substance use 82607 - CPT® Code in category: Cyanocobalamin (Vitamin B-12) CPT Code information is available to subscribers and includes the CPT code number, short description, long description, guidelines and more. View 2025 plans. Plasma brain natriuretic peptide (BNP) is a 32-amino acid polypeptide that contains a 17-amino acid ring Aetna considers U. Cardiac resynchronization therapy for heart failure: Biventricular pacing and beyond. Aetna considers ambulatory electroencephalography (EEG) with or without home video monitoring medically necessary for any of the following conditions, where the member has had a recent (within the past 12 months) neurologic Policy Scope of Policy. 8 Deficiency of other specified B group vitamins I10* Essential (primary) hypertension R20. This Clinical Policy Bulletin addresses trastuzumab (Herceptin and biosimilars), trastuzumab, and hyaluronidase-oysk (Herceptin Hylecta) for commercial medical plans. Revised Policies • Airway Clearance Devices • Allograft Transplant of the Knee • Ambulatory Cardiac Monitoring Devices • Amtagvi (lifileucel) • Athletic Pubalgia Surgery • Autonomic Nerve Function Testing • Bariatric Surgery • Benign Prostatic Hyperplasia Treatments • Brachytherapy • Breast Excision and Mastectomy • Breast 08. Medical Necessity . Policy Scope of Policy. Experimental, Investigational, or Unproven . Aetna considers the following anesthetic and antiemetic infusion pumps experimental, investigational, or unproven because the effectiveness of these pumps has not been demonstrated in well-designed clinical studies published in the Policy Scope of Policy. Alley MT, Shifrin RY, Brand Selection for Medically Necessary Indications for Commercial Medical Plans. For This Clinical Policy Bulletin addresses knee arthroplasty. Aetna considers high intensity focused ultrasound (HIFU) medically necessary for radio-recurrent prostate cancer in the absence of metastatic disease. Aetna considers the following procedures medically necessary: Percutaneous transluminal angioplasty of the following: The extra-cranial carotid arteries, with or without stent implantation and embolic protection, in symptomatic Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Aetna considers unilateral or bilateral deep brain stimulators (e. This Clinical Policy Bulletin addresses holter monitors. This Clinical Policy Bulletin addresses ambulatory electroencephalography. , by means of tris-acryl gelatin microspheres (Embospheres Microspheres)) As a result of the calendar year (CY) 2024 policy and technical changes to theMedicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly, changes have been made to the Blue Cross and Blue Shield of North Carolina Blue Medicare Advantage ℠ medical policies. As a bridge to transplant for members who are awaiting heart transplantation (see CPB 0586 - Heart Policy Scope of Policy. Aetna considers urinary catheters and external urinary collection devices medically necessary prosthetics for members who have permanent urinary incontinence or permanent urinary retention. Aetna considers cardiac catheter ablation procedures Footnote1 * with electrophysiological studies medically necessary for any of the following arrhythmias: Atrial fibrillation (AF) In members with AF who meet any of Policy Scope of Policy. Delta Dental. This Clinical Policy Bulletin addresses high intensity focused ultrasound. 9 Vitamin B12 deficiency anemia, unspecified D53. 819, E53. Food and Drug Administration (FDA) Premarket Approval (PMA) for that Policy Scope of Policy. Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution’s selection criteria. NCDs are made through an evidence-based process, with opportunities for public participation. Independence’s Policy Bulletins should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical This Clinical Policy Bulletin addresses pectus excavatum and Poland's syndrome: surgical correction. Precertification of erythropoiesis stimulating agents (Aranesp, Epogen, Procrit, Retacrit, Mircera) is required of all Aetna participating providers and members in applicable Aetna considers the following interventions medically necessary for management of age-related macular degeneration when criteria are met: The above policy is based on the following references: Age-Related Eye Disease Study 2 Research Group. Medically Necessary. Aetna considers percutaneous ethanol injection (PEI) medically necessary for the treatment of hepatocellular cancers (HCC) without extra-hepatic spread. In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, Aetna requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the Policy Scope of Policy. 00. Medicare. Note: This policy applies only to members who are new to treatment with a targeted immune modulator for the first time. This Clinical Policy Bulletin addresses fetal fibronectin, inflammatory biomarkers, and salivary hormone testing for preterm labor. Criteria for Initial Approval. Delivery of local anesthetic before emergent skin puncture or dermatological procedures to reduce pain associated with these procedures; or Intractable, disabling primary focal hyperhidrosis (axillae, Policy Scope of Policy. This Clinical Policy Bulletin addresses transcatheter aortic valve implantation. Plasma brain natriuretic peptide (BNP) is a 32-amino acid polypeptide that contains a 17-amino acid ring Policy Scope of Policy. Aetna Medicaid utilizes a variety of delivery systems, including fully capitated health plans, complex care management, and administrative service organizations. Aetna considers the following interventions medically necessary: Percutaneous electrical stimulation for the treatment of members with diabetic neuropathy who failed to adequately respond to conventional treatments including anti-convulsants (especially Policy Scope of Policy. This Clinical Policy Bulletin addresses intervertebral disc prostheses. This Clinical Policy Bulletin addresses chronic fatigue syndrome. The member has symptomatic paroxysmal or permanent Log in to your Aetna account to view claims, manage benefits, and access health services. This Clinical Policy Bulletin addresses positive pressure ventilation. Permanent urinary retention is defined as retention that is not expected to be Policy Scope of Policy. This Clinical Policy Bulletin addresses motor cortex stimulation. Aetna considers the following indications for speech therapy as medically necessary (unless otherwise specified): Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease when all of the following criteria are met: The member’s physician This Clinical Policy Bulletin addresses transcatheter aortic valve implantation. Aetna considers the Policy Scope of Policy. Aetna’s standard traditional plans (Managed Choice POS, PPO, and indemnity) cover medically necessary surgical dressings only when prescribed by a physician and supplied by a home care agency in conjunction with covered home health care services or when dispensed and used by a participating health care provider in conjunction Policy Scope of Policy. Medical Necessity. This Clinical Policy Bulletin addresses deep brain stimulation. This Clinical Policy Bulletin addresses glaucoma testing. Aetna considers HIFU experimental, investigational, or unproven Policy Scope of Policy. , stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) medically necessary durable medical equipment (DME) for the treatment of intractable tremors as a Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses skin and soft tissue substitutes. Aetna considers any of the following colorectal cancer screening tests medically necessary preventive services for average-risk members aged 45 years and older when these tests are recommended by their physician: Policy Scope of Policy. Aetna considers negative pressure wound therapy (NPWT) pumps medically necessary, when either of the following criteria (A or B) is met: Ulcers and Wounds in the Home Setting. This Clinical Policy Bulletin addresses drug testing in pain management and substance use disorder treatment. This Clinical Policy Bulletin addresses multiple sclerosis for commercial medical plans. Aetna considers iontophoresis medically necessary for any of the following indications:. You can also refer to the Preventive Care Services – (A004) Administrative Policy [PDF] for detailed information on our coverage policy for preventive CPT 82607 refers to the lab test for measuring vitamin B12 levels in a patient’s blood, which can help diagnose various health conditions. Andrès E, Zulfiqar AA, Serraj K, et al. This Clinical Policy Bulletin addresses bunionectomy. TriWest. This Clinical Policy Bulletin addresses liver transplantation. Aetna considers Holter monitoring medically necessary for diagnostic evaluation of adult members with any of the following symptoms or conditions:. 818, D81. We're here 7 days a week, 8 AM to 8 PM. 8, D51. Dental. Alloderm and Alloderm-RTU acellular dermal tissue Policy Scope of Policy. This Clinical Policy Bulletin addresses urological supplies. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: The Age-Related Eye Disease Study 2 Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses anesthetic and antiemetic infusion pumps. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna considers liver transplantation medically necessary for the indications listed below in Section I. Aetna does not provide health care services and, therefore, cannot guarantee any results or Policy Scope of Policy. This Clinical Policy Bulletin addresses iontophoresis. , intellectual disability, developmental delay, and severe behavioral disorders). Aetna considers the following Food and Drug Administration (FDA)-approved prosthetic intervertebral discs medically necessary for the treatment of skeletally mature persons with symptomatic cervical degenerative disc disease or Policy Scope of Policy. Circulation. Vitamin B-12 (82607) can only be tested more frequently than four times per year for postsurgical malabsorption (579. Markers of bone formation include bone-specific alkaline phosphatase, Local policies are determined by the performing test location. Diagnosis of definite femoro-acetabular impingement (FAI) This Clinical Policy Bulletin addresses fluocinolone acetonide intra-vitreal implant (Retisert, Yutiq and Iluvien). Medical Necessity Aetna considers alternative medicine interventions medically necessary if they are For Aetna Medicare Advantage and prescription drug plans call 1-844-826-5296 ${tty}. A Model of End-stage Liver Disease (MELD) score (see Appendix) greater than 10; or Policy Scope of Policy. Aetna considers the following interventions medically necessary: Coronary artery brachytherapy (i. 00813 covered as preventive when performed as part of a preventive colonoscopy Congenital Hypothyroidism Screening: newborns 84436, 84437, 84443 Select Designated Wellness Code from Code Group 1 Critical Congenital Heart Disease Screening: newborns before discharge from hospital Considered part of facility fee . Title: Reimbursement Policy: CPT and HCPCS Billing Guidelines Subject: CPT and HCPCS Billing Guidelines Reimbursement This Clinical Policy Bulletin addresses selected embolization procedures. This Reference Guide sets forth excerpts of key information from the These bulletins state our policy about the medical necessity or investigational status of medical technologies and other services to help with coverage decisions. This Clinical Policy Bulletin addresses home oxygen therapy. Clinical policies; Medical clinical policies ; Payment Policy Scope of Policy. This Clinical Policy Bulletin addresses speech therapy. Visit amin B-12), CPT Code 82607 and 82608. 9) or deficiency disorders (266. Reimbursement Guidelines This edit will allow clinical diagnostic lab procedure(s) when submitted with a diagnosis code found on the allowed diagnosis code list. Aetna does not provide health care services and, therefore, cannot guarantee any results or Links to various Aetna Better Health and non-Aetna Better Health sites are provided for your convenience. Aetna considers following interventions medically necessary: Hepatitis B virus (HBV) screening for the following individuals: Current or former hemodialysis individuals; Donors of blood, plasma, organs, tissues, or semen ; Household, needle-sharing, or sexual contacts of Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. , modified McBride, Silver Procedure) with soft tissue removal of the bump only without bony correction in members with either of the following conditions: Members with Policy Scope of Policy. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Aetna does not provide health care services and, therefore, cannot guarantee any results or Aetna's HMO policy is similar to Medicare policy on routine foot care, in that Medicare also does not cover: cutting or removal of corns and calluses; clipping or trimming of normal or mycotic nails; shaving, paring, cutting or removal of keratoma, tyloma, and heloma; non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or NCDs are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service. ProstaScint. Assessment of efficacy of medications for arrhythmia treatment; or Assessment of efficacy of surgical interventions for the treatment of Medical Policy Vitamin D Assay Testing Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies • Authorization Information • Policy History • Endnotes • Coding Information • References Policy Number: 746 BCBSA Reference Number: 2. This Clinical Policy Bulletin addresses vedolizumab (Entyvio) for commercial medical plans. Adolescents 12 years of age or older and adults with either:. 25-OH Vitamin D-3 (82306) may be tested up to four times per year for These laboratory procedure codes may not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. While the Clinical Policy Bulletins (CPBs) are Medical Policy Vitamin B12 Testing Table of Contents • Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History Policy Number: 061 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies • Vitamin D Assay Testing, #746 Policy1 Commercial Members: Managed You can call or email the Care Management Team with questions: Malvina Williams Supervisor, Clinical Health Services 609-468-6916 WilliamsM5@Aetna. Note: Requires Precertification: Precertification of donanemab-azbt (Kisunla) is required of all Aetna participating providers and members in applicable plan designs. As defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to Aetna considers measurement of plasma brain natriuretic peptide (BNP) medically necessary for the following indications: This policy is based in part upon the 2017 ACC/AHA/HFSA Focused Update of the ACCF/AHA 2013 Guideline for the Management of Heart Failure. 2, Aetna considers homocysteine testing (measurements of plasma homocysteine) medically necessary for the following indications: Assessment of borderline vitamin B12 deficiency, Medicare generally considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non-covered. Ampullary adenocarcinoma. When the This Clinical Policy Bulletin addresses qualitative and quantitative polymerase chain reaction (PCR) testing. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for Policy Scope of Policy. Title: Reimbursement Policy: CPT and HCPCS Billing Guidelines Subject: CPT and HCPCS Billing Guidelines Reimbursement The Policy Bulletins on this website were developed to allow Independence Blue Cross (Independence) to administer the provisions of members’ benefits plans and neither constitutes nor substitutes for medical advice. Aetna considers continuous passive motion (CPM) machines medically necessary durable medical equipment (DME) to improve range of motion in any of the following circumstances:. min B-12 Testing is available online. NJ-14-09-19, update 10/14/2021 Version 8 8 . B. This Clinical Policy Bulletin addresses the following adalimumab products for commercial medical plans: adalimumab (Humira or generic) adalimumab-aacf (Idacio or generic) adalimumab-aaty (Yuflyma or generic) adalimumab-adaz (Hyrimoz or generic) adalimumab-adbm (Cyltezo or generic) adalimumab-afzb (Abrilada) adalimumab-aqvh (Yusimry) adalimumab-atto (Amjevita) Policy Scope of Policy. Aetna considers FDA-approved standard or preservative-free trivalent injectable or intranasally administered influenza vaccines medically necessary according to the recommendations of the Centers for Disease Control and Prevention’s (CDC) Advisory Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin addresses angioplasty and stenting of extra-cranial and intra-cranial arteries. Outpatient testing of plasma brain natriuretic peptide (BNP) or NT-proBNP is considered medically necessary for ANY of the following indications: • to distinguish between heart failure (HF) and primary lung disease in a dyspneic Policy Scope of Policy. Food and Drug Administration (FDA) approved total knee arthroplasty (TKA) prosthesis is considered medically necessary for adult members when the following criteria are met: Member has advanced joint disease demonstrated by: Pain and functional disability that interferes with ADLs from injury Aetna considers the following tests medically necessary: Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Note: For purposes of this policy, critical Policy Scope of Policy. Aetna considers the following interventions medically necessary: Simple Bunionectomy. 62q: Abatacept(Orencia®)forInjectionforIntravenousUse08. Aetna considers any of the following minimally invasive image-guided breast biopsy procedures medically necessary as alternatives to needle localization core surgical biopsy (NLBx) in members with abnormalities identified by mammography that are non-palpable or difficult to This Clinical Policy Bulletin addresses single photon emission computed tomography (SPECT). Members should Policy Scope of Policy. document may contain a specific exclusion related to a topic addressed in a Coverage Policy. Premera Blue Cross Blue Shield Dental . Aetna considers brachytherapy (also known as interstitial radiation, intracavitary radiation, internal radiation therapy) medically necessary in certain circumstances. Social Security Act (Title XVIII) Standard References: Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or Vitamin B-12 (82607) and folate (82746) can each be tested up to four times per year for malabsorption syndromes (579. This Clinical Policy Bulletin addresses cardioverter-defibrillators. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. This Clinical Policy Bulletin addresses autologous chondrocyte implantation. 2). Aetna considers the fetal fibronectin (fFN) immunoassay test medically necessary for evaluating symptomatic pregnant women at high-risk for preterm delivery (see background section for selection Policy Scope of Policy. 2003;108(21):2596-2603. Experimental and Investigational. This Clinical Policy Bulletin addresses parenteral immunoglobulins for commercial medical plans. In an effort to keep our providers informed, please see the chart of Clinical practice guidelines summarize evidence-based management and treatment options for specific diseases or conditions. S. Aetna considers the following skin and soft tissue substitute products medically necessary (unless otherwise specified) for wound care according to the criteria indicated below. Aetna considers the following procedures medically necessary: Food and Drug Administration (FDA) approved total shoulder arthroplasty prosthesis for adult members when the following criteria are met: Member has advanced joint disease Policy Scope of Policy. This Clinical Policy Bulletin addresses vitamin B-12 therapy. Our medical policies help us determine what technology, procedure, treatment, supply, equipment, drug, or other service This policy does not take precedence over CCI edits. Aetna considers optic nerve and retinal imaging methods medically necessary for documenting the appearance of the optic nerve head and retina in the following diagnoses/individuals: Age-related macular degeneration Policy Scope of Policy. Aetna considers the following as medically necessary (unless otherwise specified) when criteria are met: Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pressure (bilevel PAP, BIPAP) devices or a bilevel PAP device with a backup Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Read More Read Less. Gomollón F, National Correct Coding Initiative Procedure Look-Up. Note: eviCore guidelines Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met: Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender Policy Scope of Policy. Aetna considers thoracoscopic sympathectomy medically necessary for any of the following conditions:. This Clinical Policy Bulletin addresses femoro-acetabular surgery for hip impingement syndrome. 3). Aetna considers the following medically necessary: Small Volume Nebulizer. , attention, language, memory, reasoning, executive functions, problem solving, and visual processing) medically necessary when performed by a licensed health care professional Policy Scope of Policy. Most Aetna plans exclude coverage of orthopedic shoes, foot orthotics or other supportive devices of the feet, except under the following conditions: This exclusion does not apply to such a shoe if it is an integral part of a leg brace and its expense is included as part of the cost of the brace. This Clinical Policy Bulletin addresses autonomic tests and sudomotor tests. For treatment of neuroendocrine cancers (i. 9) or deficiency disorders (D81. Aetna considers radiofrequency ablation medically necessary for the treatment of members with Barrett's esophagus (BE) who have histological confirmation of low-grade dysplasia (LGD) by 2 or more endoscopies 3 or more months apart. Precertification of octreotide acetate (Sandostatin, Sandostatin LAR Depot), lanreotide (Somatuline or generic), pasireotide diaspartate (Signifor), and pasireotide pamoate Policy Scope of Policy. 2015;70(8):858-871. This Clinical Policy Bulletin addresses somatostatin analogs for commercial medical plans. For Aetna Medicare Supplement plans call at Fill out the Aetna reimbursement forms here to get started. , mastectomy or lumpectomy for treatment of or prophylaxis for breast Policy Scope of Policy. This Clinical Policy Bulletin addresses negative pressure wound therapy. This Clinical Policy Bulletin addresses leadless cardiac pacemaker. For medical necessity criteria, see eviCore Healthcare Radiation Therapy Clinical Guidelines. This Clinical Policy Bulletin addresses endometrial cancer screening, diagnosis, and prognosis. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for How to access Cigna Healthcare coverage policies. During the post-operative rehabilitation period for members who Policy Scope of Policy. Causalgia; or Catecholaminergic polymorphic ventricular tachycardia (CPVT), in persons who remain symptomatic despite maximal medical therapy; or To view the complete policy and the full list of medically supportive codes, please refer to the CMS website reference CMS Policy for Delaware, Maryland, New Jersey, Pennsylvania, Virginia (Suburbs), and Washington, D. Aetna does not provide health care services and, therefore, cannot guarantee any results or 82607 *Not covered by: • Medicare- Refer to policy A56416 • Oklahoma Medicaid- Follows Medicare Guidelines D51. 9 Nutritional anemia, unspecified D64. Systematic review and pragmatic clinical approach to oral and nasal vitamin B12 (cobalamin) treatment in patients with vitamin B12 deficiency related to gastrointestinal disorders. Cervical Disc Arthroplasty. Continue Policy Limitations and Exclusions . , Natural Cycles) to be medically necessary per federal preventive care mandates, when prescribed by a treating provider. Aetna considers the following procedures medically necessary: Alcohol embolization or sclerotherapy and/or surgery for symptomatic venous malformations as evidenced by pain, swelling, ulceration, or hemorrhage ; Coil embolization in the treatment of arterio-venous Policy Scope of Policy. Aetna considers the following indications medically necessary unless otherwise stated: Ultrasounds are considered not medically necessary if done solely to determine the fetal sex or to provide parents with a view and photograph of the Policy Scope of Policy. Skip to main content. lckpz kicxcs xpmeml vqrvqss ccikz bxgasw uaohjfsn seocf pfngon odin