61737
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
22.10
Facility
$1350.06
Non-Facility
$1350.06
Documentation Required
- For epilepsy: documentation of disabling seizures and prior trials of ≥2 antiepileptic drug regimens.
- For epilepsy: documentation (e.g., EEG, MRI, surgical evaluation) demonstrating well-defined epileptogenic focus(s) that are anatomically accessible by LITT.
- For brain tumor/radiation necrosis: documentation that the lesion is recurrent or progressive, or imaging/surgical assessment showing lesion(s) are inaccessible to resection, or clinical documentation that the individual cannot tolerate surgical resection due to comorbidities.
- Documented treatment plan for LITT agreed upon by a multidisciplinary team of physicians.
Key Coverage Criteria
- Benign cytology ononefine needle or core biopsy;and
- Whole-gland cryosurgical ablation of the prostate is consideredmedically necessaryas a treatment of prostate cancer.
- Thermal ablation (radiofrequency ablation, cryoablation or microwave ablation) of NSCLC is consideredmedically necessarywhen all of the following criteria are met:
- Surgical or radiation treatment with curative intent is considered appropriate based on stage of disease, however medical co-morbidity renders the individual unfit for those interventions;and
- No tumor has a maximum diameter of greater than 3.0 cm;and
- Tumors are located at least 1 cm from the trachea, main bronchi, esophagus, aorta, aortic arch branches, pulmonary artery and the heart.
7 Active Policies
SUR701.031 — Laser Interstitial Tumor Therapy (LITT)
ANTHEM-CG-SURG-61 — CG-SURG-61 Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver
ANTHEM-CG-SURG-91 — CG-SURG-91 Minimally Invasive Ablative Procedures for Epilepsy
BCBSIL-SUR701.031 — Laser Interstitial Tumor Therapy (LITT)
BCBSMT-SUR701.031 — Laser Interstitial Tumor Therapy (LITT)
Related Codes
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