42826
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.36
Facility
$231.47
Non-Facility
$231.47
Documentation Required
- No explicit 'Documentation Requirements' section is provided in the excerpt. Where the policy states services or CPT codes are 'covered if selection criteria are met', those selection criteria must be met and documented in the medical record (e.g., diagnosis supporting tonsillectomy: peri-tonsillar abscess; recurrent/chronic tonsillar infection; recurrent middle ear infection with tonsillar hypertrophy as exacerbating factor; tonsillar hypertrophy causing respiratory symptoms or airway obstruction).
- For tonsillectomy indications, documentation should support the specific covered indication (e.g., clinical notes documenting peri-tonsillar abscess, number/frequency of recurrent tonsillitis episodes, relationship of tonsillar hypertrophy to middle ear infections, evidence of respiratory symptoms/airway obstruction from tonsillar hypertrophy).
- For nasal coblation plasma surgery (CPT 30801-30802) and any procedure listed as 'covered if selection criteria are met', the medical record should document the specific selection criteria used to justify the procedure (the policy references 'selection criteria' but does not enumerate them in the provided text).
Key Coverage Criteria
- Coblation of soft tissue stenosis of the external auditory canal (EAC) (case series in children with congenital/acquired EAC occlusion showing patency and symptom resolution).
- Cordotomy by Coblation (Coblator cordotomy) for treatment of bilateral vocal fold immobility (BVFI) to improve airway (multiple series including larger retrospective series reporting de-cannulation and improved Dyspnea Index/VHI outcomes).
- Coblation (RF cold ablation) for recurrent laryngotracheal respiratory papillomatosis (small series reporting longer intervals between interventions vs CO2 laser).
- Low-temperature RF Coblation for select early-stage glottic cancer (small series reporting feasibility, voice preservation, and no major complications in short follow-up).
- Coblation-assisted transoral surgery (RFC-TOS) for selected supraglottic laryngeal carcinoma and oropharyngeal squamous cell carcinoma (retrospective comparative series reporting less blood loss, shorter hospital stay, similar oncologic outcomes vs open surgery in selected patients).
- Coblation-assisted arytenoidectomy (CSA / endoscopic Coblation-assisted partial arytenoidectomy) for bilateral vocal cord paralysis in infants (case series reporting extubation success and symptomatic improvement).
4 Active Policies
AETNA-CPB-0431 — Enuresis
AETNA-CPB-0004 — Obstructive Sleep Apnea in Adults
AETNA-CPB-0475 — Coblation
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
Related Codes
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