48999
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
- Autologous pancreatic islet cell transplantation is consideredmedically necessaryas an adjunct to a total or near total pancreatectomy for individuals with chronic pancreatitis.
- Benign cytology ononefine needle or core biopsy;and
- Whole-gland cryosurgical ablation of the prostate is consideredmedically necessaryas a treatment of prostate cancer.
- Thermal ablation (radiofrequency ablation, cryoablation or microwave ablation) of NSCLC is consideredmedically necessarywhen all of the following criteria are met:
- Surgical or radiation treatment with curative intent is considered appropriate based on stage of disease, however medical co-morbidity renders the individual unfit for those interventions;and
- No tumor has a maximum diameter of greater than 3.0 cm;and
8 Active Policies
ANTHEM-MP-A053822 — TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
ANTHEM-CG-SURG-61 — CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
REGENCE-TRA13 — Islet Transplantation
BCBSIL-SUR701.031 — Laser Interstitial Tumor Therapy (LITT)
BCBSMT-SUR701.031 — Laser Interstitial Tumor Therapy (LITT)
Related Codes
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