0201T — Perq sacral augmt bilat inj
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No explicit documentation requirements (e.g., required medical records, test results, or specific clinical notes) are specified in this policy.
- From Instructions for Use: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates."
- From Instructions for Use: "This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5)."
Key Coverage Criteria
- No explicit "Covered Indications" or "Medically Necessary" indications are provided in this policy document.
- Coverage decisions are to be determined by the member specific benefit plan document (see Instructions for Use).
3 Active Policies
UHC-POL-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
UMR-POL-UMR-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
SUREST-POL-SUREST-minimally-invasive-spine-surgery — Minimally Invasive Spine Surgery Procedures
Related Codes
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