Does S9996 require prior authorization?

No, S9996 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S9996?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S9996`, Meals for clinical trial participant and one caregiver/companion

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage, but it does not guarantee coverage; reference member plan documents and guidelines.
Clinical trial must have a written protocol that describes a scientifically sound study.

Providers are not routinely required to submit trial documentation but Aetna may request supporting documentation at any time to confirm trial scientific merit and IRB approvals.

Members and providers must comply with all applicable plan requirements for precertification, registration, and referrals; related documentation must be provided as required by the plan.

Medical records, test results and clinical notes supporting medical necessity of routine care are required in the same manner as for members not enrolled in clinical trials (i.e., usual documentation to support coverage and utilization management).

Key Coverage Criteria

Cover Routine Patient Costs for a Qualifying Individual participating in an Approved Clinical Trial as required by PPACA for plan years starting on/after 2014; benefits include reasonable and necessary items/services to prevent, diagnose, and treat complications arising from participation.
Medically necessary routine patient care costs in clinical trials are covered in the same manner as routine care for members not in clinical trials.
Medically necessary treatments for conditions that result as unexpected consequences (complications) of clinical trials are covered.
Clinical trials that have a written protocol describing a scientifically sound study and that have been approved by all relevant institutional review boards (IRBs) before participants are enrolled qualify for routine care coverage (subject to other policy requirements).
Category B investigational devices and promising experimental and investigational interventions for terminal illnesses may be covered as exceptions according to Aetna's terminal illness policy and applicable benefit plan descriptions (i.e., certain investigational device Category B/terminal illness exceptions).
Routine Patient Care Costs/Services related to a clinical trial for a Qualified Individual consistent with the Families First Affordable Care Act (ACA) requirements.

9 Active Policies

UHC-POL-clinical-trials, Clinical Trials

AETNA-CPB-0466, Clinical Trials, Coverage of Routine Patient Care Costs

CIGNA-A003, Clinical Trials – (A003)

BCBSIL-ADM1001.027, Clinical Trial Treatment or Therapy

BCBSMT-ADM1001.027, Clinical Trial Treatment or Therapy

BCBSNM-ADM1001.027, Clinical Trial Treatment or Therapy

BCBSOK-ADM1001.027, Clinical Trial Treatment or Therapy

UMR-POL-UMR-clinical-trials, Clinical Trials

SUREST-POL-SUREST-clinical-trials, Clinical Trials

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S9996, Meals for clinical trial participant and one caregiver/companion