43285
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
10.21
Facility
$643.64
Non-Facility
$643.64
Documentation Required
- The article provides billing, coding, or other guidelines that complement LCD L39780 and should be used with that LCD when preparing claims.
- Report of ambulatory pH testing documenting acid exposure time (AET) > 6% must be included in the medical record.
- Upper endoscopy (EGD) report documenting findings and esophageal mucosa status (to exclude Barrett's or LA class C/D esophagitis) must be provided.
- Esophageal manometry report is required to document peristaltic function and rule out distal peristaltic amplitude < 35 mmHg.
Key Coverage Criteria
- Coverage indications follow the Local Coverage Determination (LCD) L39780; this article provides billing and coding guidelines that complement that LCD.
- Documented GERD based on abnormal ambulatory pH testing with acid exposure time (AET) > 6%.
- Completed appropriate upper endoscopic evaluation and esophageal manometry to exclude other (extra-gastroesophageal) causes of symptoms.
- Chronic GERD symptoms despite maximum (or maximum tolerated) dose of proton pump inhibitor (PPI) therapy for at least 6 months.
- Implantation performed by a surgeon experienced in laparoscopic anti-reflux procedures who has received product-specific training for magnetic sphincter augmentation.
- Patients with GERD with moderate-to-severe regurgitation, especially despite once-daily PPI treatment, should be considered for minimally invasive treatment with MSA rather than increased PPI therapy.
10 Active Policies
A59654 — Billing and Coding: Lower Esophageal Magnetic Sphincter Augmentation
L39780 — Lower Esophageal Magnetic Sphincter Augmentation
AETNA-CPB-0213 — Gastroesophageal Reflux Disease (GERD): Treatments
ANTHEM-SURG.00131 — SURG.00131 Lower Esophageal Sphincter Augmentation Devices
BCBSIL-SUR709.036 — Lower Esophageal Magnetic Sphincter Augmentation
Related Codes
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