C9768, Endoscopic ultrasound-guided direct measurement of hepatic portosystemic
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No explicit 'Documentation Requirements' section is provided in this document.
- Implied/clinical context references (not listed as formal documentation requirements): prior imaging (e.g., CT scan or MRI) or clinical evaluation for idiopathic acute pancreatitis (policy text states 'a contrast-enhanced CT scan or MRI is needed' in patients >40 years with idiopathic pancreatitis and that 'a more extensive evaluation including endoscopic ultrasound (EUS) and/or MRCP may be needed initially or after a recurrent episode of IAP'), and documentation of clinical signs/symptoms or prior non-diagnostic testing when EUS is used to evaluate suspected common bile duct stones or biliary obstruction (Cochrane review referenced standards for confirmation of stones by extraction or negative exploration or 6-month symptom-free follow-up).
- For staging and tissue sampling indications, pathology/histopathology results are often required to establish diagnosis — the policy text notes that 'biopsy and histopathologic evaluation are needed to identify the specific histology.'
Key Coverage Criteria
- Diagnosiing common bile duct stones;
- Evaluating abnormalities of the biliary tree;
- D13.0 - D13.9 Benign neoplasm of other part and ill- hyphen defined parts of digestive system
- D14.1 - D14.4 D15.2, D19.0 Benign neoplasm of larynx, trachea, bronchus and lung, pleura, and mediastinum
- Evaluating abnormalities of the gastrointestinal tract wall or adjacent structures;
- Evaluating abnormalities of the pancreas, including masses, pseudocysts and chronic pancreatitis;
6 Active Policies
AETNA-CPB-0446, Endoscopic Ultrasonography
SUR701.043, Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient Measurement
BCBSIL-SUR701.043, Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient Measurement
BCBSMT-SUR701.043, Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient Measurement
BCBSNM-SUR701.043, Endoscopic Ultrasound-Guided Direct Hepatic Portosystemic Pressure Gradient Measurement
Related Codes
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