55810
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
23.68
Facility
$1165.02
Non-Facility
$1165.02
Documentation Required
- No documentation requirements specified in this document.
- No documentation requirements (medical records, test results, or specific clinical documentation) are specified in the provided text.
- In order to determine medical necessity consistently, Humana and subsidiaries may consider the criteria contained in the following: (text indicates additional criteria/documentation will be used but the criteria are not included in this excerpt).
- Prostatectomy will be considered medically reasonable and necessary when the following requirements are met: (implies documentation must show requirements are met; specific documentation items are not listed in this excerpt).
Key Coverage Criteria
- Radical perineal prostatectomy with lymph node biopsy(s) (limited pelvic lymphadenectomy) — CPT 55812
- Open prostatectomy is a surgical procedure where the surgeon removes the prostate through an incision in the lower abdomen or, less commonly, through a perineal incision.
- Humana and subsidiaries follow the Medicare requirements that only allow coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.
- Localized prostate cancer (confined to the prostate gland).
- Prostatectomy involving removal of the prostate gland, with or without nerve sparing and surrounding tissues (usually includes the seminal vesicles and some nearby lymph nodes).
- Laparoscopic prostatectomy as a surgical technique to remove the prostate gland (described as making several small incisions in the lower abdomen and inserting special tools to remove the prostate).
1 Active Policy
HUMANA-PROSTATECTOMY-MA — Prostatectomy - Medicare Advantage
Related Codes
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