43257
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
4.05
Facility
$204.41
Non-Facility
$204.41
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity per LCD L34659, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Documentation supporting the service must be available to the Contractor upon request.
- Billing and coding must follow the Local Coverage Determination L34553 and any documentation requirements specified therein; retain medical records and coding documentation per LCD L34553.
- The patient's medical record must contain documentation that fully supports medical necessity for services included within the LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Key Coverage Criteria
- Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
- Services for select minimally invasive GERD procedures are covered when medical necessity is met as defined in the associated Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
- Adult patients (age ≥ 18) with chronic GERD symptoms (heartburn and/or regurgitation) for ≥ 6 months who are partially or completely refractory to antisecretory pharmacologic therapy are eligible for Stretta.
- Adult patients (age ≥ 18) who do not wish to continue long-term GERD medication, who are not appropriate surgical candidates, or who prefer a less invasive endoluminal alternative to laparoscopic fundoplication may be considered for Stretta.
- Transoral Incisionless Fundoplication (TIF, e.g., EsophyX) is covered when performed by a well-trained surgeon for symptomatic chronic gastroesophageal reflux disease (GERD) with symptoms present for >6 months.
17 Active Policies
A56395 — Billing and Coding: Endoscopic Treatment of GERD
J05
L34659 — Endoscopic Treatment of GERD
J05
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
L35080 — Select Minimally Invasive GERD Procedures
J06
A57414
Related Codes
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