43653
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.27
Facility
$565.14
Non-Facility
$565.14
Documentation Required
- (not specified in this excerpt) — the excerpt does not provide explicit documentation requirements.
- (inferred) Documentation supporting medical necessity for the adjustment: operative report showing placement of the gastric restrictive device and date of original surgery (to establish the global period), clinical notes describing symptoms or need for adjustment, and records showing the adjustment occurred after the global period.
- (inferred) Documentation required by the referenced LCD for surgical management of morbid obesity: objective evidence of morbid obesity (e.g., BMI), comorbidity documentation where applicable, and documentation of prior conservative weight-loss attempts if required by the LCD.
- No specific documentation requirements are stated in this document.
Key Coverage Criteria
- Surgical management of morbid obesity (referenced LCD L33411 / A57145 — First Coast Service Options).
- No specific covered indications are stated in this document. The policy defers coverage determinations to applicable CMS NCDs/LCDs/LCAs and the local Medicare Administrative Contractor (MAC).
- Exact text: '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.'
- Related policies referenced (not stated as covered indications here): 'Gastric Pacing/Gastric Electrical Stimulation' and 'Vagus Nerve Stimulation'
- Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1).
- Laparoscopic Sleeve Gastrectomy (LSG) — referenced as a medical policy article (A52447) indicating LSG is addressed in coverage/policy guidance.
1 Active Policy
HUMANA-BARIATRIC-SURGERY-MA — Bariatric Surgery - Medicare Advantage
Related Codes
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