46930
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.57
Facility
$157.65
Non-Facility
$247.83
Documentation Required
- No explicit documentation requirements (medical records, test results, or other specific documentation) are specified in this Clinical Policy Bulletin.
- Implied documentation to support coverage would include documentation of the covered diagnosis (e.g., anal dysplasia K62.82 or grade I/II internal hemorrhoids K64.0-K64.1) and clinical evidence that hemorrhoids are painful or persistently bleeding, but the policy does not list required forms, timeframes, or specific tests.
Key Coverage Criteria
- Infrared coagulation (IRC) for the treatment of internal hemorrhoids (Grade I and Grade II).
- Infrared coagulation (IRC) as an outpatient therapy for hemorrhoids (used as a non-surgical outpatient therapy).
- IRC ablation of anal high-grade squamous intraepithelial lesions (HSILs) / anal dysplasia (studies demonstrating increased HSIL clearance vs monitoring).
- Infrared coagulation medically necessary for anal dysplasia.
- Infrared coagulation medically necessary for members with grade I or grade II internal hemorrhoids that are painful or persistently bleeding.
- Infrared light treatment is considered medically necessary as a heat modality in physical therapy.
1 Active Policy
AETNA-CPB-0604 — Infrared Therapy
Related Codes
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