M0100 — Intragastric hypothermia using gastric freezing
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
- No documentation requirements are specified in this Clinical Policy Bulletin.
- No specific documentation requirements or required medical records/test results are specified in this CPB. (The policy primarily identifies tests/procedures considered obsolete/not covered and lists associated CPT/HCPCS/ICD-10 codes.)
Key Coverage Criteria
- Implicit from policy: gastric freezing (intragastric hypothermia) is NOT covered — see Experimental and Investigational section: "Aetna considers gastric freezing (intragastric hypothermia) experimental and investigational for chronic peptic ulcer disease or any other indications because there is insufficient evidence to support its effectiveness for these indications."
- None. Aetna considers gastric freezing (intragastric hypothermia) experimental and investigational for chronic peptic ulcer disease or any other indications because there is insufficient evidence to support its effectiveness for these indications.
- None specified. This Clinical Policy Bulletin addresses obsolete and unreliable tests and procedures and lists tests/procedures that Aetna considers experimental and investigational (i.e., not covered).
2 Active Policies
AETNA-CPB-0438 — Obsolete and Unreliable Tests and Procedures
AETNA-CPB-0527 — Intragastric Hypothermia
Related Codes
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