Does 95991 require prior authorization?

No, 95991 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 95991?

Medicare facility rate: $33.73. Non-facility rate: $115.90. Work RVU: 0.75.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.75

Facility

$33.73

Non-Facility

$115.90

Medical record must document that the patient is unresponsive to less invasive medical therapy and this documentation must be available upon Medical Review request.
Record must include evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist, or other specialist familiar with the disease confirming failure of other treatments and lack of other reasonable options.
Legible physician medical documentation meeting the policy criteria must be maintained; lacking justification or illegible notes will result in denial.
Documentation of the preliminary intrathecal/epidural trial must record the degree of pain relief, side effects (including effects on activities of daily living), and patient acceptance and compliance.

Implantable infusion pumps are covered when used to administer opioid drugs, alone or in combination with other opioid or non-opioid drugs, via the intrathecal or epidural route.
Covered for treatment of severe chronic intractable pain of malignant or nonmalignant origin when the patient has a life expectancy of at least 3 months.
Coverage requires that the pain is unresponsive to less invasive medical therapy, including systemic opioids, combinations of oral analgesics plus adjuvant pain drugs, or other noninvasive approaches.
The administration must require the intrathecal or epidural route, be expected to be effective on a long-term basis, and oral or subcutaneous medication must be ineffective or cause unacceptable side effects.
An evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist, or other specialist familiar with the underlying disease is required to validate that other treatments have failed and no other reasonable options are available at the time of evaluation.
A preliminary trial using a temporary intrathecal or epidural catheter must be undertaken prior to implantation to substantiate acceptable pain relief, degree of side effects (including effects on activities of daily living), and patient acceptance and compliance.

A55239 — Billing and Coding: Implantable Infusion Pumps for Chronic Pain

A56695 — Billing and Coding: Implantable Infusion Pump

L33461 — Implantable Infusion Pump

A55323 — Billing and Coding: Implantable Infusion Pumps for Chronic Pain

AETNA-CPB-0442 — Lysosomal Storage Disorder Treatments

Ask Verity about documentation requirements, denial risks, or coverage in your state.