Does 61735 require prior authorization?

No, 61735 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 61735?

Medicare facility rate: $1571.18. Non-facility rate: $1571.18. Work RVU: 21.79.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

21.79

Facility

$1571.18

Non-Facility

$1571.18

If CPT codes 61720 or 61735 are billed, clinical documentation should support the selection criteria referenced by the CPB (i.e., the indication of terminal cancer pain as a last resort).
No explicit documentation requirements section provided in policy.
Implied documentation requirements: documentation that the procedure is a 'last resort' for terminal cancer pain (i.e., record of terminal cancer diagnosis and that other appropriate pain treatments have been tried and failed), and that care is provided in the context of palliative/terminal care (ICD-10 Z51.5).
Policy notes and cited consensus/guidelines emphasize need for strict inclusion criteria, multidisciplinary evaluation, documented refractoriness to standard therapies, and proper consent procedures (as described in background and references), although these are not enumerated as specific required documentation items in the CPB.

Stereotactic cingulotomy medically necessary when used as a last resort to provide pain relief for members with terminal cancer pain.
ICD-10 G89.3 — Neoplasm related pain (acute) (chronic) [used as a last resort to provide pain relief for members with terminal cancer pain]
ICD-10 Z51.5 — Encounter for palliative care [terminal care]
CPT codes 61720 and 61735 covered if selection criteria are met (creation of lesion by stereotactic method, see CPT table).
The treatment of medically refractory epilepsy using stereotactic laser techniques (MRI-guided laser interstitial thermal ablation [MRIgLITT]), including stereotactic laser amygdalohippocampotomy (SLAH), is consideredmedically necessarywhen both of the following criteria are met:
Documented disabling seizures despite the use of two or more tolerated antiepileptic drug regimens;and

AETNA-CPB-0288 — Stereotactic Cingulotomy and Capsulotomy

ANTHEM-CG-SURG-91 — CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy

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