Description
Documentation will be reviewed to determine whether transurethral waterjet ablation services met Medicare coverage criteria and were reasonable and necessary.
Affected Code(s)
0421T, C2596
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986 Good Cause for Reopening
7. Medicare Benefit Policy Manual, Chapter 14, §10 Coverage of Medical Devices
8. Medicare Claims Processing Manual, Chapter 23, §30 Services Paid Under the Medicare Physician’s Fee Schedule
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in an LCD
11. CGS Administrators, LLC - LCD L38378 - Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective 04/01/2020; revised 10/22/2023
12. CGS Administrators, LLC - LCA A57926 - Billing and Coding: Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective Date 04/01/2020; revised 10/22/2023
13. First Coast LCD L38726 - Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
14. First Coast LCA A58264 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
15. National Government Services, Inc. - LCD L38367 - Fluid Jet System Treatment for LUTS/BPH; Effective date 04/01/2020; revised 11/01/2020
16. National Government Services, Inc. - LCA A56797 - Billing and Coding: Fluid Jet System Treatment for LUTs/BPH; Effective date 04/01/2020; revised 11/01/2020
17. Noridian LCD L38705 - Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
18. Noridian LCD L38707 - Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
19. Noridian LCA A58227 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
20. Noridian LCA A58229 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
21. Novitas LCD L38712 - Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
22. Novitas LCA A58243 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
23. Palmetto LCD - L38549 Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; revised 01/29/2023
24. Palmetto LCA A58008 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; effective 12/27/2020; revised 01/29/2023
25. WPS LCD L38682 - Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; revised 10/15/2023
26. WPS LCA A58209 - Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; revised 10/27/2022
27. HCPCS Level II Codebook