Does A4649 require prior authorization?

Yes, A4649 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for A4649?

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

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`A4649`, Surgical supply; miscellaneous

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When an ABN is used, Form CMS-R-131 must be signed by the beneficiary; for Part A MAC claims include occurrence code 32 and the ABN date on the claim.

Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.

Hospital inpatient claims must report the principal diagnosis in UB-04 FL67 and the admitting diagnosis in FL69, with up to eight additional ICD-10-CM codes in FLs 67A-67Q as applicable.

Hospital outpatient claims must report the full ICD-10-CM code for the diagnosis responsible for the outpatient service in UB-04 FL67 and list up to eight other diagnoses in FLs 67A-67Q.

When lymphoscintigraphy is performed in the radiology department prior to surgery, document and code the procedure separately as a radiology service under the appropriate revenue code.

Key Coverage Criteria

Sentinel lymph node biopsy is covered for identification, removal, and pathologic evaluation of sentinel lymph nodes to stage and assess regional lymph node metastasis for malignant tumors.
Preoperative lymphoscintigraphy to locate sentinel node(s) is covered and should be reported separately when performed prior to the surgical procedure.
Injection of radioactive tracer or vital dye for sentinel node localization is covered when performed without lymphoscintigraphy or when performed by the operating surgeon, reported with the appropriate injection code.
Under Medicare Part B, CPT codes 38500, 38510, 38525 and 38530 are payable in inpatient hospital (21), outpatient hospital (22) and ambulatory surgical center (24) places of service.
CPT codes 38792, 38900 and 78195 are payable in office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), and independent clinic (49); CPT 78195 global/TC is payable in office (11) and independent clinic (49).
Medicare covers surgical dressings that are reasonable and necessary for diagnosis or treatment of illness or injury, for improving function of a malformed body member, and that meet all other Medicare statutory and regulatory requirements.

7 Active Policies

ANTHEM-MED.00110, Silver-based Products for Wound and Soft Tissue Applications

ANTHEM-SURG.00162, Implantable Shock Absorber for Treatment of Knee Osteoarthritis

ANTHEM-CG-MED-96, Prefabricated External Infant Ear Molding Systems

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

A52437, Billing and Coding: Sentinel Lymph Node Biopsy Medical Policy Article

L33831, Surgical Dressings

AETNA-CPB-0526, Surgical Devices, Dressings, and Wound Care Supplies

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A4649, Surgical supply; miscellaneous