0947T — Mrgfus strtctc bl-br disrpj
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
- For metastatic bone pain: documentation that the patient declined, failed, or is not a candidate for radiotherapy (clinical notes or prior treatment records).
- For essential tremor: documentation of medication-refractory status, including trials of relevant medications (e.g., beta-blockers, anticonvulsants) and reasons for failure or intolerance.
- Documentation that the patient is pre- or perimenopausal and has symptomatic uterine fibroids.
- Documentation that the patient has completed childbearing (for uterine fibroid indication).
Key Coverage Criteria
- Pain palliation in adults with metastatic bone cancer who have declined, failed, or are not candidates for radiotherapy.
- Treatment of medication-refractory essential tremor (e.g., failed or intolerant to beta-blockers or anticonvulsant drugs).
- Noninvasive treatment of uterine fibroids
- Pain palliation for bone metastases
- Metastatic bone disease causing cancer-related pain in patients who have not responded to conservative measures (e.g., massage, exercise) and pharmacologic agents (e.g., analgesics, bisphosphonates, corticosteroids).
- Persistent/residual pain from metastatic bone disease after standard external-beam radiotherapy requiring alternative treatment.
5 Active Policies
SUR701.022 — Magnetic Resonance-Guided Focused Ultrasound
BCBSIL-SUR701.022 — Magnetic Resonance-Guided Focused Ultrasound
BCBSMT-SUR701.022 — Magnetic Resonance-Guided Focused Ultrasound
BCBSNM-SUR701.022 — Magnetic Resonance-Guided Focused Ultrasound
BCBSOK-SUR701.022 — Magnetic Resonance-Guided Focused Ultrasound
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