Does 43250 require prior authorization?

No, 43250 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 43250?

Medicare facility rate: $152.64. Non-facility rate: $498.68. Work RVU: 2.90.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.90

Facility

$152.64

Non-Facility

$498.68

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).

Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
EGD is covered for persistent upper abdominal distress (e.g., gastroesophageal reflux disease) that continues despite an appropriate trial of symptomatic therapy.
EGD is covered for upper abdominal distress accompanied by a short history of concerning signs or symptoms such as weight loss, anorexia, vomiting, or NSAID/other gastric irritant intake.
EGD is covered for patients older than 40 years who have a significant history of heartburn that recurs after a course of symptomatic therapy.
EGD is covered for patients with dysphagia or odynophagia.

L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy

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A57063 — Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

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L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

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A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

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Ask Verity about documentation requirements, denial risks, or coverage in your state.