49999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity per LCD L34659, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Documentation supporting the service must be available to the Contractor upon request.
- The patient's medical record must contain documentation that fully supports medical necessity for services included within the LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Key Coverage Criteria
- Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
- Services for select minimally invasive GERD procedures are covered when medical necessity is met as defined in the associated Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.
- Transoral Incisionless Fundoplication (TIF, e.g., EsophyX) is covered when performed by a well-trained surgeon for symptomatic chronic gastroesophageal reflux disease (GERD) with symptoms present for >6 months.
- Coverage is appropriate only when symptoms are not completely responsive to proton pump inhibitor (PPI) therapy as documented by GERD-HRQL score >=20 after being off PPIs for 14 days, or by a reduction in GERD-HRQL score >=10 between off-therapy and on-therapy states.
- TIF is covered when performed for hiatal hernia in accordance with FDA-approved indications.
- Transoral incisionless fundoplication (TIF) using the EsophyX device for treatment of gastroesophageal reflux disease (GERD) is covered to reconstruct the gastroesophageal valve and reduce acid reflux.
10 Active Policies
L34659 — Endoscopic Treatment of GERD
J05
A56395 — Billing and Coding: Endoscopic Treatment of GERD
J05
L35080 — Select Minimally Invasive GERD Procedures
J06
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
BCBSNM-SUR705.036
Related Codes
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