Does A9268 require prior authorization?

No, A9268 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for A9268?

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

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`A9268`, Programmer for transient, orally ingested capsule

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

General: documentation of prior conservative treatments attempted and their failure as described (diet, bowel habit changes, laxatives, medications) when coverage is predicated on failed conservative management.
When a device is considered experimental/investigational in the policy (e.g., ingestible vibrating capsule, PIE, rectal inserts), medical records demonstrating rationale will not convert the device to covered — policy states these are not covered because effectiveness not established.

Documentation that 'initial management involving diet, bowel habit, laxatives or constipating medications has failed' is required for coverage of manual pump enema systems (Peristeen) for chronic neurogenic bowel (text: "...when initial management involving diet, bowel habit, laxatives or constipating mediations has failed").

Documentation that 'selection criteria is met' for the specific device / HCPCS is required when codes are listed as 'covered if selection criteria is met' (the policy repeatedly lists items followed by the caveat 'covered if selection criteria is met').

Appropriate diagnostic documentation to support covered ICD-10 codes for the indication (e.g., K59.2 for chronic neurogenic bowel; K56.600-K56.699 for intestinal obstruction when a stent is used) — policy lists these ICD-10 codes as the covered diagnoses for devices/stents.

Key Coverage Criteria

Manual pump enema systems (e.g., Peristeen Anal Irrigation System, Coloplast, Minneapolis, MN) for the management of chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating mediations has failed
Gravity-administered enema systems for the treatment of constipation, fecal incontinence, and bowel management protocols
Use of a stent for bowel obstruction due to colorectal malignancy for palliation and as a bridge to surgery.
HCPCS A4458 (Enema bag with tubing, reusable) — covered if selection criteria is met
HCPCS A4453 (Rectal catheter for use with the manual pump-operated enema system, replacement only) — covered if selection criteria is met
HCPCS A4459 (Manual pump-operating enema system, including balloon, catheter and all accessories, reusable, any type) — covered for chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating medications have failed

2 Active Policies

ANTHEM-MED.00143, Ingestible Devices for the Treatment of Constipation

AETNA-CPB-0522, Bowel Management Devices

`A9268`, Programmer for transient, orally ingested capsule

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

A9268, Programmer for transient, orally ingested capsule

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

`A9268`, Programmer for transient, orally ingested capsule