43453
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.37
Facility
$77.49
Non-Facility
$831.68
Documentation Required
- Documentation of prior treatments and treatment failures where applicable (e.g., prior pneumatic dilation, prior Heller myotomy, prior botulinum toxin injection) — several POEM reports specify use as 'rescue' after failed prior interventions.
- For stent placement or palliative radiotherapy: documentation of inoperable/unresectable primary esophageal cancer and symptom burden (dysphagia score), and life expectancy considerations (to guide stent vs brachytherapy selection).
- No explicit documentation requirements, test-result requirements, or medical-record documentation instructions are specified in this document excerpt.
- Objective pre- and post-treatment measures used in trials and expected in documentation: Eckardt score, LES resting pressure (manometry), timed barium esophagogram results (esophageal emptying), EndoFLIP/EGJ distensibility where used, and follow-up endoscopy/pH monitoring for reflux after POEM.
Key Coverage Criteria
- Telerehabilitation delivery of swallowing therapy (as an alternative delivery model; limited evidence)
- Speech therapy for treatment of dysphagia, regardless of the presence of a communication disability, for members who meet the criteria set forth below:
- Member exhibits weight loss or malnutrition because he/she has dysphagia and is unable to obtain adequate nutrition orally;
- Member has a history of, or is at high-risk for, recurrent aspirations or choking;
- Member is unable to swallow and has a nasogastric or gastrotomy tube for nutrition;
- Esophageal dilation for the treatment of symptomatic obstruction of the esophagus;
1 Active Policy
AETNA-CPB-0625 — Dysphagia Therapy
Related Codes
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