A4639 — Replacement pad for infrared heating pad system, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted.
- For DMEPOS base items requiring Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO (WOPD) before delivering the item to the beneficiary.
- When a WOPD is required for a base item that may have separately billed accessories, the WOPD must list the base item and may list the associated separately billed options/accessories/supplies prior to delivery.
- Suppliers are required to maintain proof of delivery (POD) documentation in their files and make POD available to the Medicare contractor upon request.
Key Coverage Criteria
- There are no covered indications for infrared therapy devices; CMS NCD 270.6 found no therapeutic effect and the device and related accessories are denied as not medically reasonable and necessary.
- Infrared coagulation (IRC) for the treatment of internal hemorrhoids (Grade I and Grade II).
- Infrared coagulation (IRC) as an outpatient therapy for hemorrhoids (used as a non-surgical outpatient therapy).
- IRC ablation of anal high-grade squamous intraepithelial lesions (HSILs) / anal dysplasia (studies demonstrating increased HSIL clearance vs monitoring).
- Infrared coagulation medically necessary for anal dysplasia.
- Infrared coagulation medically necessary for members with grade I or grade II internal hemorrhoids that are painful or persistently bleeding.
8 Active Policies
L33825 — Infrared Heating Pad Systems
J19
AETNA-CPB-0729 — Diabetic Neuropathy: Selected Treatments
BCBSIL-DME101.045 — Infrared Therapy Devices
BCBSMT-DME101.045 — Infrared Therapy Devices
BCBSNM-DME101.045 — Infrared Therapy Devices
Related Codes
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