G0516, Insertion of non-biodegradable drug delivery implants, 4 or more (services for
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.77
Facility
$84.84
Non-Facility
$175.02
Documentation Required
- Clinical evidence demonstrating therapy effectiveness for the relevant diagnosis (peer‑reviewed literature or authoritative compendia citations).
- For drug therapy, documentation of proposed dose, frequency, and duration with reference to at least one authoritative source (e.g., FDA label, DrugDex, NCCN, MCG).
- References to supporting FDA labeling, compendia, or professional guidelines when used to justify coverage.
- Members and providers must consult the member's benefit plan, summary plan description, or contract to determine applicable coverage, exclusions, and limitations.
Key Coverage Criteria
- Therapies covered when proven effective for the relevant diagnosis based on peer‑reviewed scientific literature or authoritative compendia.
- Drug therapy covered when proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source (e.g., FDA label, DrugDex, NCCN, MCG).
- Coverage decisions supported by FDA‑approved labeling and/or nationally recognized authoritative references and standards of medical practice.
- Coverage of any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services, even if the FDA has not approved the drug for that indication.
- Coverage of FDA‑approved drugs for off‑label uses supported by medical literature when safety and efficacy have been confirmed in two articles from major peer‑reviewed sources.
- Off-label drug use may be covered when supported by peer-reviewed professional medical journals and robust study designs (e.g., randomized, double-blind, placebo-controlled clinical trials).
9 Active Policies
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Related Codes
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