Amniotic Membrane and Amniotic Fluid

Policy ID: S-249-019

Section: Surgery

Effective Date: November 01, 2019

Revised Date: March 18, 2024

Revision Effective Date: April 01, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Human amniotic membrane (HAM) forms the innermost layer of the placenta and is harvested from the time of caesarean section. It is cleaned, sterilized and cryo-preserved or dehydrated and can be utilized to facilitate wound healing in diabetic and venous ulcers or sutured onto ocular surfaces.

Amniotic fluid contains a concentration of growth factors and nutrients that promote healing in soft-tissue repair of bone, tendon and cartilage, as well as reducing inflammation and pain, in conditions such as osteoarthritis and plantar fasciitis.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Treatment of nonhealing* diabetic lower-extremity ulcers using ANY of the following HAM products may be considered medically necessary:

Affinity®; or
AmnioBand® Membrane; or
Biovance®; or
Epifix®; or
Grafix™.

Note: Nonhealing is defined as less than a 20% decrease in wound area with standard wound care for at least two (2) weeks.

All other HAM products for the treatment of non-healing diabetic lower-extremity ulcers not meeting the criteria as indicated in this policy are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

65778

Q4132

Q4133

Q4151

Q4154

Q4159

Q4168

Q4186

Treatment of non-healing venous stasis ulcers using Grafix may be considered medically necessary when BOTH of the following criteria are met:

Partial- or full-thickness venous stasis ulcer of greater than four (4) weeks duration for which standard wound therapy has failed; and
Treated lower extremity has adequate blood supply as evidenced by either the presence of a palpable pedal pulse or an ankle-brachial index (ABI) of greater than or equal to 0.70

When the above medical necessity criteria are met, the following conditions of coverage apply:

Treatment is limited to one (1) initial application
Additional applications at a minimum of one (1) week intervals, for up to a maximum of four (4) in 12 weeks are considered medically necessary when evidence of wound healing is present (e.g., signs of epithelialization and reduction in ulcer size)

Additional applications beyond 12 weeks are considered not medically necessary regardless of wound status

All other HAM products for the treatment of venous stasis ulcers not meeting the criteria as indicated in this policy are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

Q4133

Sutured human amniotic membrane HAM grafts may be considered medically necessary for the treatment of ANY of the following ophthalmic indications:

Neurotrophic keratitis; or
Corneal ulcers and melts; or
Pterygium repair; or
Stevens-Johnson syndrome; or
Persistent epithelial defects.*

Note: A persistent epithelial defect is one that failed to close completely after five (5) days of conservative treatment or has failed to demonstrate a decrease in size after two (2) days of conservative treatment. Conservative treatment is defined as use of topical lubricants and/or topical antibiotics and/or therapeutic contact lens and/or patching.

Sutured HAM grafts not meeting the criteria as indicated in this policy are considered experimental/investigational and, therefore, non-covered conditions because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

65779

Q4100

V2790

Human amniotic membrane (HAM) grafts without suture (Prokera®, AmbioDisk™) may be considered medically necessary for the treatment of the following ophthalmic indications:

Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy; or
Corneal ulcers and melts that do not respond to initial conservative therapy; or
Corneal perforation when there is active inflammation after corneal transplant requiring adjunctive treatment; or
Bullous keratopathy as a palliative measure in individuals who are not candidates for curative treatment (e.g., endothelial or penetrating keratoplasty); or
Partial limbal stem cell deficiency with extensive diseased tissue where selective removal alone is not sufficient; or
Moderate or severe Stevens-Johnson syndrome; or
Persistent epithelial defects that do not respond within two (2) days to conservative therapy; or
Severe dry eye (DEWS 3 or 4) with ocular surface damage and inflammation that remains symptomatic after Steps 1, 2, and 3 of the dry eye disease management algorithm; or
Moderate or severe acute ocular chemical burn.

Human amniotic membrane without suture for ophthalmic indications not meeting the criteria as indicated in this policy is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature

Procedure Codes

65778

Q4100

HAM grafts without suture not meeting the criteria as indicated in this policy are considered experimental/investigational and, therefore, non-covered conditions because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

A2022

A2023

Q4137

Q4138

Q4140

Q4148

Q4150

Q4153

Q4156

Q4157

Q4160

Q4163

Q4169

Q4170

Q4173

Q4176

Q4178

Q4180

Q4183

Q4184

Q4185

Q4187

Q4188

Q4189

Q4190

Q4191

Q4192

Q4194

Q4195

Q4198

Q4199

Q4201

Q4204

Q4205

Q4208

Q4209

Q4210

Q4211

Q4214

Q4216

Q4217

Q4218

Q4219

Q4221

Q4224

Q4225

Q4227

Q4229

Q4230

Q4231

Q4232

Q4233

Q4234

Q4235

Q4236

Q4237

Q4239

Q4240

Q4241

Q4242

Q4245

Q4246

Q4247

Q4248

Q4249

Q4250

Q4251

Q4252

Q4253

Q4254

Q4255

Q4256

Q4257

Q4258

Q4259

Q4260

Q4261

Q4262

Q4263

Q4264

Q4265

Q4266

Q4267

Q4268

Q4269

Q4270

Q4271

Q4272

Q4273

Q4274

Q4275

Q4276

Q4277

Q4278

Q4279

Q4280

Q4281

Q4282

Q4283

Q4284

Q4285

Q4286

Q4287

Q4288

Q4289

Q4290

Q4291

Q4292

Q4293

Q4294

Q4295

Q4296

Q4297

Q4298

Q4299

Q4300

Q4301

Q4302

Q4303

Q4304

Q4305

Q4306

Q4307

Q4308

Q4309

Q4310

The following are considered experimental/investigational and, therefore, non-covered for all indications because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

Injection of micronized or particulated human amniotic membrane; and
Injection of human amniotic fluid

Procedure Codes

Q4100

Q4139

Q4145

Q4155

Q4162

Q4171

Q4174

Q4177

Q4206

Q4212

Q4213

Q4215

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes Q4132, Q4151, Q4154, Q4159, Q4168 and Q4186

*L97 codes must be billed with one of the following codes from this section: E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.201

L97.202

L97.203

L97.204

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Q4133

*L97 codes must be billed with one of the following codes from this section: E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

I83.001

I83.011

I83.021

I83.201

I83.211

I83.221

I83.002

I83.012

I83.022

I83.202

I83.212

I83.222

I83.003

I83.013

I83.023

I83.203

I83.213

I83.223

I83.004

I83.014

I83.024

I83.204

I83.214

I83.224

I83.005

I83.015

I83.025

I83.205

I83.215

I83.225

I83.008

I83.018

I83.028

I83.208

I83.218

I83.228

I83.009

I83.019

I83.029

I83.209

I83.219

I83.229

L97.111

L97.112

L97.113

L97.114

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Procedure Codes 65779, Q4100 and V2790

H11.001

H11.002

H11.003

H11.011

H11.012

H11.013

H11.021

H11.022

H11.023

H11.031

H11.032

H11.033

H11.041

H11.042

H11.043

H11.051

H11.052

H11.053

H11.061

H11.062

H11.063

H16.001

H16.002

H16.003

H16.011

H16.012

H16.013

H16.021

H16.022

H16.023

H16.031

H16.032

H16.033

H16.041

H16.042

H16.043

H16.051

H16.052

H16.053

H16.061

H16.062

H16.063

H16.071

H16.072

H16.073

H16.231

H16.232

H16.233

H18.501

H18.502

H18.503

H18.509

H18.511

H18.512

H18.513

H18.519

H18.521

H18.522

H18.523

H18.529

H18.531

H18.532

H18.533

H18.539

H18.541

H18.542

H18.543

H18.549

H18.551

H18.552

H18.553

H18.559

H18.591

H18.592

H18.593

H18.599

H18.831

H18.832

H18.833

L51.1

Covered Diagnosis Codes for procedure code 65778

H04.121

H04.122

H04.123

H04.129

H16.071

H16.072

H16.073

H16.079

H16.401

H16.402

H16.403

H16.409

H16.411

H16.412

H16.413

H16.419

H16.421

H16.422

H16.423

H16.429

H16.431

H16.432

H16.433

H16.439

H16.441

H16.442

H16.443

H16.449

H18.10

H18.11

H18.12

H18.13

H18.30

H18.52

H18.831

H18.832

H18.833

H18.839

H18.891

H18.892

H18.893

H18.899

I87.2

T26.10XA

T26.10XD

T26.10XS

T26.11XA

T26.11XD

T26.11XS

T26.12XA

T26.12XD

T26.12XS

T26.20XA

T26.20XD

T26.20XS

T26.21XA

T26.21XD

T26.21XS

T26.22XA

T26.22XD

T26.22XS

T26.31XA

T26.31XD

T26.31XS

T26.32XA

T26.32XD

T26.32XS

T26.40XA

T26.40XD

T26.40XS

T26.41XA

T26.41XD

T26.41XS

T26.42XA

T26.42XD

T26.50XA

T26.50XD

T26.50XS

T26.51XA

T26.51XD

T26.51XS

T26.52XA

T26.52XD

T26.52XS

T26.60XA

T26.60XD

T26.60XS

T26.61XA

T26.61XD

T26.61XS

T26.62XA

T26.62XD

T26.62XS

T26.70XA

T26.70XD

T26.70XS

T26.71XA

T26.71XD

T26.71XS

T26.72XA

T26.72XD

T26.72XS

T26.80XA

T26.80XD

T26.80XS

T26.81XA

T26.81XD

T26.81XS

T26.82XA

T26.82XD

T26.82XS

T26.90XA

T26.90XD

T26.90XS

T26.91XA

T26.91XD

T26.91XS

T26.92XA

T26.92XD

T26.92XS

T260.42XS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New Policy for ND

Internal Medical Policy Committee 5-19-2020 Effective July 1, 2020

Adding Application codes 15271 through 15278
Coding- HCPCS Update

Internal Medical Policy Committee 9-21-2020 Coding update:

Added Procedure codes Q4249; Q4250; Q4254; Q4255; and
Added Covered Diagnosis Codes for Procedure Codes: 65779; Q4100 and V2790
- H18.501; H18.502; H18.503; H18.509; H18.511; H18.512; H18.513; H18.519; H18.521; H18.522; H18.523; H18.529; H18.531; H18.532; H18.533; H18.539; H18.541; H18.542; H18.543; H18.549; H18.551; H18.552; H18.553; H18.559; H18.591; H18.592; H18.593; and H18.599

Internal Medical Policy Committee 1-19-2021

Added Diansosis codes,
Expanded medically necessary criteria, and
Prokera®, AmbioDisk were E/I prior, now have criteria.

Internal Medical Policy Committee 9-21-2021- Coding update

Removed Q4228; Q4236; and
Added procedure codes Q4251; Q4252; and Q4253.

Internal Medical Policy Committee 11-23-2021 Revision update in criteria

Added CPT code Q4199

Internal Medical Policy Committee 7-21-2022 Coding update - Effective July 01, 2022

Added Procedure codes Q4259; Q4260; and Q4261.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 01, 2023

Added procedure codes Q4236; Q4262; Q4263; and Q4264.

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added new procedure codes Q4265; Q4266; Q4267; Q4268; Q4269; Q4270; and Q4271.

Internal Medical Policy Committee 7-26-2023 Codingupdate -Effective July 01, 2023

Added procedure codes Q4272; Q4273; Q4274; Q4275; Q4276; Q4277; Q4278; Q4280; Q4281; Q4282; Q4283; Q4284.

InternalMedical Policy Committee 11-15-2023 Codingupdate -Effective October 01, 2023

Added procedure codes A2022; A2023; Q4285; and Q4286.

InternalMedical Policy Committee 1-16-2024 Coding update -Effective January 01, 2024

Added new procedure codes: Q4279; Q4287; Q4288; Q4289; Q4290; Q4291; Q4292; Q4293; Q4294; Q4295; Q4296; Q4297; Q4298; Q4299; Q4300; Q4301; Q4302; Q4303; and Q4304.

Internal Medical Policy Committee 3-19-2024 Coding update- Effective April 01, 2024

Removed procedure code Q4244; and
Added procedure codes Q4305; Q4306; Q4307; Q4308; Q4309; and Q4310; and
Added Policy Application

Links

Reference (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-249-018

Section: Surgery

Effective Date: November 01, 2019

Revised Date: December 11, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: January 16, 2024

Archived Date: March 31, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Treatment of nonhealing* diabetic lower-extremity ulcers using ANY of the following HAM products may be considered medically necessary:

Affinity®; or
AmnioBand® Membrane; or
Biovance®; or
Epifix®; or
Grafix™.

Note: Nonhealing is defined as less than a 20% decrease in wound area with standard wound care for at least two (2) weeks.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

65778

Q4132

Q4133

Q4151

Q4154

Q4159

Q4168

Q4186

Treatment of non-healing venous stasis ulcers using Grafix may be considered medically necessary when BOTH of the following criteria are met:

Partial- or full-thickness venous stasis ulcer of greater than four (4) weeks duration for which standard wound therapy has failed; and
Treated lower extremity has adequate blood supply as evidenced by either the presence of a palpable pedal pulse or an ankle-brachial index (ABI) of greater than or equal to 0.70

When the above medical necessity criteria are met, the following conditions of coverage apply:

Treatment is limited to one (1) initial application
Additional applications at a minimum of one (1) week intervals, for up to a maximum of four (4) in 12 weeks are considered medically necessary when evidence of wound healing is present (e.g., signs of epithelialization and reduction in ulcer size)

Additional applications beyond 12 weeks are considered not medically necessary regardless of wound status

Procedure Code

Q4133

Sutured human amniotic membrane HAM grafts may be considered medically necessary for the treatment of ANY of the following ophthalmic indications:

Neurotrophic keratitis; or
Corneal ulcers and melts; or
Pterygium repair; or
Stevens-Johnson syndrome; or
Persistent epithelial defects.*

Procedure Codes

65779

Q4100

V2790

Human amniotic membrane (HAM) grafts without suture (Prokera®, AmbioDisk™) may be considered medically necessary for the treatment of the following ophthalmic indications:

Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy; or
Corneal ulcers and melts that do not respond to initial conservative therapy; or
Corneal perforation when there is active inflammation after corneal transplant requiring adjunctive treatment; or
Bullous keratopathy as a palliative measure in individuals who are not candidates for curative treatment (e.g., endothelial or penetrating keratoplasty); or
Partial limbal stem cell deficiency with extensive diseased tissue where selective removal alone is not sufficient; or
Moderate or severe Stevens-Johnson syndrome; or
Persistent epithelial defects that do not respond within two (2) days to conservative therapy; or
Severe dry eye (DEWS 3 or 4) with ocular surface damage and inflammation that remains symptomatic after Steps 1, 2, and 3 of the dry eye disease management algorithm; or
Moderate or severe acute ocular chemical burn.

Procedure Codes

65778

Q4100

Procedure Codes

A2022

A2023

Q4137

Q4138

Q4140

Q4148

Q4150

Q4153

Q4156

Q4157

Q4160

Q4163

Q4169

Q4170

Q4173

Q4176

Q4178

Q4180

Q4183

Q4184

Q4185

Q4187

Q4188

Q4189

Q4190

Q4191

Q4192

Q4194

Q4195

Q4198

Q4199

Q4201

Q4204

Q4205

Q4208

Q4209

Q4210

Q4211

Q4214

Q4216

Q4217

Q4218

Q4219

Q4221

Q4224

Q4225

Q4227

Q4229

Q4230

Q4231

Q4232

Q4233

Q4234

Q4235

Q4236

Q4237

Q4239

Q4240

Q4241

Q4242

Q4244

Q4245

Q4246

Q4247

Q4248

Q4249

Q4250

Q4251

Q4252

Q4253

Q4254

Q4255

Q4256

Q4257

Q4258

Q4259

Q4260

Q4261

Q4262

Q4263

Q4264

Q4265

Q4266

Q4267

Q4268

Q4269

Q4270

Q4271

Q4272

Q4273

Q4274

Q4275

Q4276

Q4277

Q4278

Q4279

Q4280

Q4281

Q4282

Q4283

Q4284

Q4285

Q4286

Q4287

Q4288

Q4289

Q4290

Q4291

Q4292

Q4293

Q4294

Q4295

Q4296

Q4297

Q4298

Q4299

Q4300

Q4301

Q4302

Q4303

Q4304

Injection of micronized or particulated human amniotic membrane; and
Injection of human amniotic fluid

Procedure Codes

Q4100

Q4139

Q4145

Q4155

Q4162

Q4171

Q4174

Q4177

Q4206

Q4212

Q4213

Q4215

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes Q4132, Q4151, Q4154, Q4159, Q4168 and Q4186

*L97 codes must be billed with one of the following codes from this section: E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.201

L97.202

L97.203

L97.204

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Q4133

*L97 codes must be billed with one of the following codes from this section: E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

I83.001

I83.011

I83.021

I83.201

I83.211

I83.221

I83.002

I83.012

I83.022

I83.202

I83.212

I83.222

I83.003

I83.013

I83.023

I83.203

I83.213

I83.223

I83.004

I83.014

I83.024

I83.204

I83.214

I83.224

I83.005

I83.015

I83.025

I83.205

I83.215

I83.225

I83.008

I83.018

I83.028

I83.208

I83.218

I83.228

I83.009

I83.019

I83.029

I83.209

I83.219

I83.229

L97.111

L97.112

L97.113

L97.114

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Procedure Codes 65779, Q4100 and V2790

H11.001

H11.002

H11.003

H11.011

H11.012

H11.013

H11.021

H11.022

H11.023

H11.031

H11.032

H11.033

H11.041

H11.042

H11.043

H11.051

H11.052

H11.053

H11.061

H11.062

H11.063

H16.001

H16.002

H16.003

H16.011

H16.012

H16.013

H16.021

H16.022

H16.023

H16.031

H16.032

H16.033

H16.041

H16.042

H16.043

H16.051

H16.052

H16.053

H16.061

H16.062

H16.063

H16.071

H16.072

H16.073

H16.231

H16.232

H16.233

H18.501

H18.502

H18.503

H18.509

H18.511

H18.512

H18.513

H18.519

H18.521

H18.522

H18.523

H18.529

H18.531

H18.532

H18.533

H18.539

H18.541

H18.542

H18.543

H18.549

H18.551

H18.552

H18.553

H18.559

H18.591

H18.592

H18.593

H18.599

H18.831

H18.832

H18.833

L51.1

Covered Diagnosis Codes for procedure code 65778

H04.121

H04.122

H04.123

H04.129

H16.071

H16.072

H16.073

H16.079

H16.401

H16.402

H16.403

H16.409

H16.411

H16.412

H16.413

H16.419

H16.421

H16.422

H16.423

H16.429

H16.431

H16.432

H16.433

H16.439

H16.441

H16.442

H16.443

H16.449

H18.10

H18.11

H18.12

H18.13

H18.30

H18.52

H18.831

H18.832

H18.833

H18.839

H18.891

H18.892

H18.893

H18.899

I87.2

T26.10XA

T26.10XD

T26.10XS

T26.11XA

T26.11XD

T26.11XS

T26.12XA

T26.12XD

T26.12XS

T26.20XA

T26.20XD

T26.20XS

T26.21XA

T26.21XD

T26.21XS

T26.22XA

T26.22XD

T26.22XS

T26.31XA

T26.31XD

T26.31XS

T26.32XA

T26.32XD

T26.32XS

T26.40XA

T26.40XD

T26.40XS

T26.41XA

T26.41XD

T26.41XS

T26.42XA

T26.42XD

T26.50XA

T26.50XD

T26.50XS

T26.51XA

T26.51XD

T26.51XS

T26.52XA

T26.52XD

T26.52XS

T26.60XA

T26.60XD

T26.60XS

T26.61XA

T26.61XD

T26.61XS

T26.62XA

T26.62XD

T26.62XS

T26.70XA

T26.70XD

T26.70XS

T26.71XA

T26.71XD

T26.71XS

T26.72XA

T26.72XD

T26.72XS

T26.80XA

T26.80XD

T26.80XS

T26.81XA

T26.81XD

T26.81XS

T26.82XA

T26.82XD

T26.82XS

T26.90XA

T26.90XD

T26.90XS

T26.91XA

T26.91XD

T26.91XS

T26.92XA

T26.92XD

T26.92XS

T260.42XS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New Policy for ND

Internal Medical Policy Committee 5-19-2020 Effective July 1, 2020

Adding Application codes 15271 through 15278
Coding- HCPCS Update

Internal Medical Policy Committee 9-21-2020 Coding update:

Added Procedure codes Q4249; Q4250; Q4254; Q4255
Added Covered Diagnosis Codes for Procedure Codes: 65779; Q4100 and V2790
- H18.501; H18.502; H18.503; H18.509; H18.511; H18.512; H18.513; H18.519; H18.521; H18.522; H18.523; H18.529; H18.531; H18.532; H18.533; H18.539; H18.541; H18.542; H18.543; H18.549; H18.551; H18.552; H18.553; H18.559; H18.591; H18.592; H18.593; and H18.599

Internal Medical Policy Committee 1-19-2021

Added Diansosis codes,
Expanded medically necessary criteria, and
Prokera®, AmbioDisk were E/I prior, now have criteria.

Internal Medical Policy Committee 9-21-2021- Coding update

Removed Q4228 and Q4236
Added procedure codes Q4251, Q4252, Q4253

Internal Medical Policy Committee 11-23-2021 Revision update in criteria

Added CPT code Q4199

Internal Medical Policy Committee 7-21-2022 Coding update - Effective July 01, 2022

Added Procedure codes Q4259; Q4260 and Q4261

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 01, 2023

Added procedure codes Q4236, Q4262, Q4263, Q4264

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added new procedure codes Q4265; Q4266; Q4267; Q4268; Q4269; Q4270; and Q4271.

Internal Medical Policy Committee 7-26-2023 Codingupdate -Effective July 01, 2023

Added procedure codes Q4272; Q4273; Q4274; Q4275; Q4276; Q4277; Q4278; Q4280; Q4281; Q4282; Q4283; Q4284.

InternalMedical Policy Committee 11-15-2023 Codingupdate -Effective October 01, 2023

Added procedure codes A2022, A2023, Q4285, and Q4286

InternalMedical Policy Committee 1-16-2024 Coding update -Effective January 01, 2024

Added new procedure codes: Q4279, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, and Q4304

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