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12437 Results

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels

Service Code
77771 (CPT) Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels

Service Code
77772 (CPT) Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed

Service Code
77778 (CPT) Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Surface application of low dose rate radionuclide source

Service Code
77789 (CPT) Surface application of low dose rate radionuclide source
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Supervision, handling, loading of radiation source

Service Code
77790 (CPT) Supervision, handling, loading of radiation source
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

78267 UREA BREATH TEST, C-14; ACQUISITION FOR ANALYSIS

Service Code
78267 (CPT) 78267 UREA BREATH TEST, C-14; ACQUISITION FOR ANALYSIS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

78268 UREA BREATH TEST, C-14; ANALYSIS

Service Code
78268 (CPT) 78268 UREA BREATH TEST, C-14; ANALYSIS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dialysis Service

Service Code
78300 (CPT) Bone and/or joint imaging; limited area
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

  • a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

  • b. access maintenance performed by the staff in the ESRD facility;
  • c. take home drugs and supplies;
  • d. specimen collection fees;
  • e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

  • f. medical supply charges, including syringes and their administration;
  • g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

  • h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

Dialysis Service

Service Code
78305 (CPT) Bone and/or joint imaging; multiple areas
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

  • a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

  • b. access maintenance performed by the staff in the ESRD facility;
  • c. take home drugs and supplies;
  • d. specimen collection fees;
  • e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

  • f. medical supply charges, including syringes and their administration;
  • g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

  • h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

Dialysis Service

Service Code
78306 (CPT) Bone and/or joint imaging; whole body
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

  • a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

  • b. access maintenance performed by the staff in the ESRD facility;
  • c. take home drugs and supplies;
  • d. specimen collection fees;
  • e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

  • f. medical supply charges, including syringes and their administration;
  • g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

  • h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry

Service Code
78350 (CPT) Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry, 1 or more sites

Service Code
78351 (CPT) Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry, 1 or more sites
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations

Service Code
78414 (CPT) Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cardiac shunt detection

Service Code
78428 (CPT) Cardiac shunt detection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan

Service Code
78429 (CPT) Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed to

Service Code
78430 (CPT) Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed to
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired compute

Service Code
78431 (CPT) Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired compute
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);

Service Code
78432 (CPT) Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently a

Service Code
78433 (CPT) Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently a
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)

Service Code
78434 (CPT) Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required