93580
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
17.52
Facility
$844.04
Non-Facility
$844.04
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to the protocol titled 'Medical Records Documentation Used for Reviews')
- Imaging documentation confirming a history of cryptogenic stroke
- Documentation of multidisciplinary agreement: statement/notes that a cardiologist and a neurologist agree the stroke is likely embolic in nature
- Documentation that other causes of ischemic stroke have been ruled out, including, but not limited to, carotid disease, hypercoagulable states, and atrial fibrillation (clinical workup notes, test results, monitoring records)
Key Coverage Criteria
- Percutaneous patent foramen ovale (PFO) closure for the prevention of recurrent ischemic stroke when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions and all of the following criteria are met:
- History of cryptogenic stroke confirmed by imaging
- A cardiologist and a neurologist agree that the stroke is likely embolic in nature
- Other causes of ischemic stroke have been ruled out, including but not limited to carotid disease, hypercoagulable states, or atrial fibrillation
- Individual is 18-60 years of age
- FDA device-specific indication (informational): PFO closure is indicated to reduce the risk of recurrent ischemic stroke in patients, predominantly between the ages of 18 and 60 years, who have had a cryptogenic stroke due to a presumed paradoxical embolism, as determined by a neurologist and cardiologist following an evaluation to exclude known causes of ischemic stroke (per Amplatzer and Gore PMAs cited)
9 Active Policies
AETNA-CPB-0707 — Headaches: Invasive Procedures
CARELON-catheter-based-closure-of-patent-foramen-ovale-2024-11-01 — Catheter Based Closure of Patent Foramen Ovale
UHC-POL-percutaneous-patent-foramen-ovale-closure — Percutaneous Patent Foramen Ovale (PFO) Closure
UMR-POL-UMR-percutaneous-patent-foramen-ovale-closure — Percutaneous Patent Foramen Ovale (PFO) Closure
Related Codes
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