Does A4639 require prior authorization?

No, A4639 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4639?

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

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`A4639`, Replacement pad for infrared heating pad system, each

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

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted.
For DMEPOS base items requiring Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO (WOPD) before delivering the item to the beneficiary.

When a WOPD is required for a base item that may have separately billed accessories, the WOPD must list the base item and may list the associated separately billed options/accessories/supplies prior to delivery.

Suppliers and claims must meet additional documentation and payment rules described in the LCD-related Standard Documentation Requirements Article, LCD-related Policy Article, the Supplier Manual, and DME MAC web site bulletins prior to Medicare reimbursement.

Items/services must be correctly coded per CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles; correct coding documentation must be maintained.

Key Coverage Criteria

There are no covered indications for infrared therapy devices; CMS NCD 270.6 found no therapeutic effect and the device and related accessories are denied as not medically reasonable and necessary.
Infrared coagulation (IRC) for the treatment of internal hemorrhoids (Grade I and Grade II).
Infrared coagulation (IRC) as an outpatient therapy for hemorrhoids (used as a non-surgical outpatient therapy).
IRC ablation of anal high-grade squamous intraepithelial lesions (HSILs) / anal dysplasia (studies demonstrating increased HSIL clearance vs monitoring).
Infrared coagulation medically necessary for anal dysplasia.
Infrared coagulation medically necessary for members with grade I or grade II internal hemorrhoids that are painful or persistently bleeding.

7 Active Policies

L33825, Infrared Heating Pad Systems

AETNA-CPB-0604, Infrared Therapy

AETNA-CPB-0729, Diabetic Neuropathy: Selected Treatments

BCBSIL-DME101.045, Infrared Therapy Devices

BCBSMT-DME101.045, Infrared Therapy Devices

BCBSNM-DME101.045, Infrared Therapy Devices

BCBSOK-DME101.045, Infrared Therapy Devices

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A4639, Replacement pad for infrared heating pad system, each