43499
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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.
- 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.
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.
- Botulinum toxin injections are covered when medical necessity is documented according to the Local Coverage Determination (LCD) 'Botulinum Toxin Types A and B' Indications and Limitations of Coverage.
- Approved formulations include Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA), and Myobloc (rimabotulinumtoxinB); when a formulation is used for an indication not listed in the AHFS, a physician statement explaining the reason(s) for the unapproved form must be in the medical record.
- Focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's cramp, laryngeal spasm, and dysphonia are recognized indications for which prior failure of traditional therapies is not required to document medical necessity.
- 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.
20 Active Policies
A56395 — Billing and Coding: Endoscopic Treatment of GERD
J05
L34659 — Endoscopic Treatment of GERD
J05
L35080 — Select Minimally Invasive GERD Procedures
J06
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
WPS-L34659
Related Codes
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