Does 59072 require prior authorization?

No, 59072 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 59072?

Medicare facility rate: $462.94. Non-facility rate: $462.94. Work RVU: 8.77.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

8.77

Facility

$462.94

Non-Facility

$462.94

For thoraco-amniotic shunt (TAS) and pleuro-amniotic shunt: ultrasound documentation of fetal pleural effusion/macro-cystic lung lesion and hydrops, gestational age, pre-procedure counseling, and post-procedure imaging showing reduction in effusion/lesion size and hydrops resolution where applicable.
For fetal cardiac interventions (e.g., FAV): detailed fetal echocardiography demonstrating critical aortic stenosis with echocardiographic predictors of evolving HLHS (e.g., valve z-scores, ventricular dimensions, pressure gradients), gestational age (mid-gestation candidates), multidisciplinary counseling documentation, and plan for postnatal management and follow-up; documentation that center has required expertise and registry/quality reporting where applicable.
For LUTO and vesico-amniotic shunting: ultrasound documentation of LUTO (megacystis, oligohydramnios), fetal urine studies results if performed (to assess renal prognosis), counseling about perinatal and long-term renal outcomes, technical plan for shunt placement, and follow-up imaging; note need to document risk of shunt displacement/obstruction and plan for neonatal follow-up.

CPT codes covered if selection criteria are met: 59001 (Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance))
In utero fetal surgery for ablation of anastomotic vessels in acardiac twins
In utero fetal surgery for insertion of pleuro-amniotic shunt for fetal pleural effusion
In utero fetal surgery for laser ablation or occlusion of anastomotic vessels in early, severe (stages II to IV) twin-twin transfusion syndrome (see Appendix for staging classification)
In utero fetal surgery for removal of sacrococcygeal teratoma
In utero fetal surgery for repair of myelomeningocele

AMBETTER-CP.MP.129 — Fetal Surgery in Utero for Prenatally Diagnosed Malformations

AETNA-CPB-0449 — Fetal Surgery In Utero

BCBSIL-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations

BCBSMT-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations

BCBSNM-SUR701.016 — Fetal Surgery for Prenatally Diagnosed Malformations

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