49905
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.38
Facility
$314.97
Non-Facility
$314.97
Documentation Required
- For decisions about preoperative biliary drainage: documentation of rationale for PBD if performed given evidence that routine PBD may increase infectious complications
- Operative and peri-operative records documenting reconstruction technique (antecolic vs retrocolic), use of Braun anastomosis, omental/falciform wraps, stent placement, fibrin patch application, and rationale for such adjuncts (since evidence varies and practices may be individualized)
- No explicit 'Documentation Requirements' section is provided in the text. (The policy repeatedly states that codes/procedures are 'covered if selection criteria are met' but does not list the selection criteria.)
- Inferred documentation to support coverage (not explicitly listed in the CPB) should include: clinical diagnosis corresponding to a covered ICD-10 code (e.g., pathology or imaging confirming pancreatic adenocarcinoma, IPMN with high-grade dysplasia or invasive cancer, neuroendocrine tumor, chronic pancreatitis, duodenal neoplasm, ampullary carcinoma/adenoma, cholangiocarcinoma, combined pancreatic/duodenal injury)
Key Coverage Criteria
- Surgical resection of endocrine tumors (gastrinomas) including management of Zollinger-Ellison syndrome (ZES), with and without multiple endocrine neoplasia type 1 (MEN1)
- Resection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas
- C24.1 Malignant neoplasm of ampulla of Vater
- D13.2 Benign neoplasm of duodenum
- D13.5 Benign neoplasm of extrahepatic bile ducts
- Pancreaticoduodenectomy (also known as Whipple resection) : CPT codes covered if selection criteria are met : 48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple- hyphen type procedure); with pancreatojejunostomy
1 Active Policy
AETNA-CPB-0365 — Pancreaticoduodenectomy (Whipple Resection)
Related Codes
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