43180
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.80
Facility
$478.97
Non-Facility
$478.97
Documentation Required
- Daily symptom measurements during temporary stimulation sessions (as done in Abell et al).
- Gastric emptying testing (solid GET) performed before and after temporary GES (Shine et al).
- Electrogastrography (EGG) recordings (cutaneous and/or mucosal) at baseline and after temporary GES, including measures of frequency, amplitude, frequency-amplitude ratio, and propagation; specifically baseline mucosal EGG recorded following mucosal lead placement but before stimulator activation (recommended by Abell et al).
- Definition of response to temporary stimulation when used as a predictive test (example used in Corvinus et al: response defined as a 50% decrease of baseline GCSI).
Key Coverage Criteria
- Revision or replacement of a previously approved gastric stimulator implant for complications associated with gastric pacing (eg, bowel obstruction, gastric wall perforation, infection, lead dislodgement or lead erosion into the small intestine).
- EGG (electrogastrography) can be valuable in the diagnosis of delayed gastric emptying and can identify patients who may require GES.
- Temporary GES (via endoscopic mucosal leads, percutaneous electrodes, or laparoscopic temporary electrodes) may be used to select responders to permanent implantation and to help define optimal electrode implantation sites.
- Gastric pacing (gastric pacemaker) and gastric electrical stimulation for the treatment of symptoms of nausea and vomiting from chronic gastroparesis, where the diagnosis is confirmed by gastric emptying scintigraphy, that is refractory to medical management (including dietary modification, antiemetics, and prokinetics).
- Per-oral endoscopic myotomy for the treatment of Zenker diverticulum.
- Gastric per-oral endoscopic myotomy (G-POEM) for members with severe gastroparesis who meet all of the following criteria: (1) Diagnosis of gastroparesis has been confirmed by a gastric emptying study (GES), where abnormal GES was defined as gastric retention greater than 60% at 2 hours and/or 10% at 4 hours after meal ingestion; (2) Symptom duration has been greater than 6 months; and (3) Member has had an inadequate response to conservative treatment of gastroparesis, including dietary modific [...]
1 Active Policy
AETNA-CPB-0678 — Gastric Pacing / Electrical Stimulation and Gastroesophageal Per Oral Endoscopic Myotomy
Related Codes
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