Does 43280 require prior authorization?

No, 43280 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 43280?

Medicare facility rate: $1012.05. Non-facility rate: $1012.05. Work RVU: 17.65.

Verity

`43280`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

17.65

Facility

$1012.05

Non-Facility

$1012.05

Documentation Required

No specific documentation requirements, required medical records, test results, or clinical documentation are specified in the provided text.
No explicit documentation requirements are stated in the provided excerpt.
No documentation requirements are specified in the provided text.
No documentation requirements (medical records, test results, or clinical documentation) are specified in the provided excerpt.

Key Coverage Criteria

Treatment of achalasia
Treatment of gastroesophageal reflux disease (GERD)
Treatment of hiatal hernia
Humana and subsidiaries apply a Medicare Administrative Contractor's (MAC's) LCD to all requests (both Part A and Part B services) within the MAC's applicable geographic jurisdiction (coverage determined by the applicable MAC LCD).
Endoluminal plication or suturing: Creates plications (folds) in the esophageal wall that purportedly narrows the opening and prevents acid reflux.
No explicit clinical indications, diagnoses, or covered conditions are provided in this excerpt.

3 Active Policies

HUMANA-TREATMENT-OF-ACHALASIA-GASTROESOPHAGEAL-REFLUX-DISEASE-AND-HIATAL-HERNIA-MA — Treatment of Achalasia, Gastroesophageal Reflux Disease and Hiatal Hernia - Medicare Advantage

ANTHEM-CG-SURG-92 — CG-SURG-92 Paraesophageal Hernia Repair

REGENCE-SUR186 — Gastroesophageal Reflux Surgery

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43280