47399
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For epilepsy: documentation of disabling seizures and prior trials of ≥2 antiepileptic drug regimens.
- For epilepsy: documentation (e.g., EEG, MRI, surgical evaluation) demonstrating well-defined epileptogenic focus(s) that are anatomically accessible by LITT.
- For brain tumor/radiation necrosis: documentation that the lesion is recurrent or progressive, or imaging/surgical assessment showing lesion(s) are inaccessible to resection, or clinical documentation that the individual cannot tolerate surgical resection due to comorbidities.
- Documented treatment plan for LITT agreed upon by a multidisciplinary team of physicians.
Key Coverage Criteria
- General Criteria(both 1and2 below):Used as part of the acquisition, collection and storage of a covered and medically necessary organ transplant;andInvolving donor organ(s) initially deemed unacceptable for procurement and transplantation based on limitations of cold storage preservation;and
- Used as part of the acquisition, collection and storage of a covered and medically necessary organ transplant;and
- Involving donor organ(s) initially deemed unacceptable for procurement and transplantation based on limitations of cold storage preservation;and
- Classified as Maastricht category III (persons who became donors after controlled withdrawal of life support and subsequent cardiac arrest and cardiocirculatory death);and
- Portable normothermic organ perfusion systems are consideredmedically necessarywhen the following criteria are met (both criteria set Aandcriteria set B):
- Organ-Specific Criteria(1or2or3 below):Lungperfusion (for example, Organ Care System Lungâ¢) involving donor lung pairs withone or moreof the following risk factors:Donor after circulatory death (DCD);orAge greater than 55 years;orPaO2/FiO2 less than 300 mmHg;orIschemic time greater than 6 hours;orLiverperfusion when criteria are met (aorb below):Organ Care System Liver: liver allograftsFrom DCD less than or equal to 55 years old;andWith less than or equal to 30 minutes of warm ischemic time;an [...]
12 Active Policies
ANTHEM-MP-E001734 — TRANS.00039 Portable Normothermic Organ Perfusion Systems
ANTHEM-CG-SURG-78 — CG-SURG-78 Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver
BCBSIL-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
BCBSMT-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
BCBSNM-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
Related Codes
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