ICD-10 J80 is officially defined as "Acute respiratory distress syndrome." code J80 is referenced in 8 tracked payer policy changes from Health Net and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code J80 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Health Net updated 24 medical policies in Q2 2020, including new prior authorization requirements for burn surgery and skin substitutes, coverage changes for various procedures, and updated billing codes for multiple specialties. Key changes include new COVID-19 testing guidelines, updated ADHD assessment criteria, and revised coverage for mechanical stretching devices.
This policy update includes multiple changes to prior authorization requirements, coverage criteria, and billing codes across various medical services. Key changes include new policies for burn surgery and pediatric oral therapy, updates to ADHD assessment criteria, new COVID-19 testing guidelines, and various code additions/deletions that may affect payment.
CalViva Health updated medical policies for Q2 2020 affecting Medi-Cal members in Fresno, Kings, and Madera counties. Multiple policies were added or revised with new coverage criteria, code updates, and prior authorization requirements for various procedures including burn surgery, cardiac rehabilitation, genetic testing, and COVID-19 diagnostics.
Aetna considers ECMO medically necessary for neonates who meet all of these criteria: a listed diagnosis (congenital diaphragmatic hernia, hyaline membrane disease, meconium aspiration, persistent fetal circulation, possible cardiac anomaly, refractory neonatal septic shock, respiratory distress syndrome, or uncontrollable air leak), gestational age of at least 34 weeks, birth weight of 2,000 grams or greater, and age less than 10 days (preferably less than 7 days). For children and adults, ECMO and extracorporeal life support are considered medically necessary for listed diagnoses when the risk of death is very high despite optimal conventional therapy, including ARDS, a short-term bridge to heart, liver, lung or heart-lung transplantation or to durable mechanical circulatory support, support following heart surgery to ease the transition from cardiopulmonary bypass to ventilation, non-necrotizing pneumonias, primary graft failure after transplant, pulmonary contusion, refractory pediatric septic shock, smoke inhalation injury, and other reversible causes of respiratory or cardiac failure unresponsive to all other measures. Aetna considers ECMO experimental, investigational, or unproven for all other indications, including acute coronary syndromes, acute massive pulmonary embolism, burns not accompanied by ARDS, cardiogenic shock or smoke inhalation injury, sepsis other than refractory pediatric septic shock, refractory status asthmaticus, tuberculosis, and drug overdose.
Aetna considers inhaled nitric oxide (INO) therapy medically necessary as a component of the treatment of hypoxic respiratory failure in neonates 34 weeks gestation or greater when criteria are met, for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease, and as a method of assessing pulmonary vaso-reactivity in persons with pulmonary hypertension. Aetna considers INO therapy experimental, investigational, or unproven for all other indications, including acute bronchiolitis, acute respiratory distress syndrome, sickle cell disease vaso-occlusive crises, COVID-19 related pneumonia, and traumatic brain injury. The policy lists no specific CPT code for INO therapy.
Aetna covers Aralast NP, Glassia, Prolastin-C and Zemaira for emphysema caused by alpha1-antitrypsin deficiency when the member's pretreatment serum AAT level is below 11 micromol/L, the pretreatment post-bronchodilation FEV1 is 25% to 80% of predicted, and the member has a PiZZ, PiZ (null) or Pi (null, null) genotype or another phenotype or genotype linked to that serum level, without PiMZ or PiMS. Aetna also covers these products for steroid-refractory acute graft-versus-host disease following hematopoietic stem cell transplantation, and continues emphysema treatment when the member shows a beneficial clinical response. Aetna considers all other indications experimental, investigational or unproven and requires precertification for these products in applicable plan designs.
Aetna's Clinical Policy Bulletin 0814 considers remote ischemic conditioning experimental, investigational, or unproven for many indications because its effectiveness has not been established. The listed indications include acute coronary syndromes in individuals undergoing percutaneous coronary intervention, prevention of contrast-induced acute kidney injury, improvement of outcomes in individuals with acute ischemic stroke undergoing intravenous thrombolysis, improvement of outcomes following orthopedic surgery, sepsis management, and treatment of ulcerative colitis. The bulletin states that there are no specific codes for remote ischemic conditioning.
Aetna considers ECMO medically necessary for neonates who have one of the listed diagnoses, including congenital diaphragmatic hernia, meconium aspiration, persistent fetal circulation, respiratory distress syndrome, or uncontrollable air leak, when the neonate has a gestational age of at least 34 weeks, a birth weight of 2,000 grams or greater, and an age under 10 days (preferably under 7 days). For children and adults, ECMO and ECLS are considered medically necessary when the risk of death is very high despite optimal conventional therapy, for indications such as ARDS, a short-term bridge to heart, liver, lung or heart-lung transplantation, a short-term bridge to durable mechanical circulatory support, and smoke inhalation injury. Aetna considers ECMO experimental, investigational, or unproven for all other indications, including COVID-19 in persons not meeting the medical necessity criteria, sepsis other than refractory pediatric septic shock, acute coronary syndromes, and tuberculosis.
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