00106
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Cryoablation treatment.
- *Note: The American Gastroenterological Association recommends that LGD should be confirmed by two pathologists since published studies have reported higher rates of progression of LGD when initial readings have been confirmed by expert pathologists, thereby eliminating or minimizing the rate of false positive diagnoses of LGD.
- I. High grade dysplasia (HG) or Intramucosal cancer (IMC):
- Ablative treatment of Barrettâs esophagus is consideredmedically necessarywhen the following criterion have been met (A, B,andC):
- The pathology findings includeeitherof the following:High grade dysplasia (HG);orIntramucosal cancer (IMC);and
- High grade dysplasia (HG);or
2 Active Policies
ANTHEM-CG-SURG-101 — CG-SURG-101 Ablative Techniques as a Treatment for Barrettâs Esophagus
ANTHEM-CG-MED-59 — CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
Related Codes
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