Does A4264 require prior authorization?

No, A4264 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4264?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`A4264`, Permanent implantable contraceptive intratubal occlusion device(s) and delivery

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Clinical notes supporting that the patient is certain about desire for permanent sterilization (i.e., not uncertain about ending fertility) and has not had prior tubal ligation if hysteroscopic approach is being considered.
Hysterosalpingogram is necessary three months after surgery to verify micro-insert placement and tubal occlusion (manufacturer labeling / prescribing information) — i.e., modified HSG confirmation testing at three months

Catheterization and introduction of saline or contrast material for SIS or hysterosalpingography may be performed three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion (CPT 58340) — documentation of performed imaging and results required when applicable

Hysterosalpingography radiological supervision and interpretation documentation at three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion (CPT 74740) — documentation of performed imaging and results required when applicable

Prescribing information / FDA requirements (for Essure while it was distributed): providers/facilities must provide patients information about risks and benefits and give patients the opportunity to sign an acknowledgement of understanding before implantation (documentation of patient counseling/acknowledgement implied)

Per policy/appendix: documentation to exclude contraindications is required (e.g., absence of active or recent pelvic infection; not pregnant or within 6 weeks postpartum/ post-termination; no known allergy to contrast media; not previously tubally ligated; patient is certain she desires permanent sterility)

Key Coverage Criteria

Laparoscopy with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) when indicated (CPT 58661)
Laparoscopy with lysis of adhesions with occlusion of oviducts by device (CPT 58671)
Salpingectomy, complete or partial, unilateral or bilateral as separate procedure (CPT 58700)
Catheterization and introduction of saline or contrast for saline infusion sonohysterography (SIS) or hysterosalpingography (HSG) (CPT 58340) — specifically allowed for confirmation (three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion)
Hysterosalpingography, radiological supervision and interpretation (CPT 74740) — specifically allowed three months after hysteroscopic tubal sterilization to verify insert placement and tubal occlusion
ICD-10 diagnosis code Z30.2 (Encounter for sterilization) as covered diagnosis when selection criteria are met

`A4264`, Permanent implantable contraceptive intratubal occlusion device(s) and delivery

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

A4264, Permanent implantable contraceptive intratubal occlusion device(s) and delivery

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

1 Active Policy

Related Codes

Have a follow-up question?

`A4264`, Permanent implantable contraceptive intratubal occlusion device(s) and delivery