A9268 — Programmer for transient, orally ingested capsule
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- General: documentation of prior conservative treatments attempted and their failure as described (diet, bowel habit changes, laxatives, medications) when coverage is predicated on failed conservative management.
- When a device is considered experimental/investigational in the policy (e.g., ingestible vibrating capsule, PIE, rectal inserts), medical records demonstrating rationale will not convert the device to covered — policy states these are not covered because effectiveness not established.
- Documentation that 'initial management involving diet, bowel habit, laxatives or constipating medications has failed' is required for coverage of manual pump enema systems (Peristeen) for chronic neurogenic bowel (text: "...when initial management involving diet, bowel habit, laxatives or constipating mediations has failed").
Key Coverage Criteria
- Manual pump enema systems (e.g., Peristeen Anal Irrigation System, Coloplast, Minneapolis, MN) for the management of chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating mediations has failed
- Gravity-administered enema systems for the treatment of constipation, fecal incontinence, and bowel management protocols
- Use of a stent for bowel obstruction due to colorectal malignancy for palliation and as a bridge to surgery.
- HCPCS A4458 (Enema bag with tubing, reusable) — covered if selection criteria is met
- HCPCS A4453 (Rectal catheter for use with the manual pump-operated enema system, replacement only) — covered if selection criteria is met
- HCPCS A4459 (Manual pump-operating enema system, including balloon, catheter and all accessories, reusable, any type) — covered for chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating medications have failed
2 Active Policies
AETNA-CPB-0522 — Bowel Management Devices
ANTHEM-MED.00143 — MED.00143 Ingestible Devices for the Treatment of Constipation
Related Codes
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