Friday, December 10, 2010

wireless capsule endoscopy - coverage - DX 043.3

Wireless Capsule Endoscopy for Medicare Plans

Policy #: DIAGNOSTIC 043.3 T3
Coverage Statement:
Policy is applicable to:

AARP MedicareComplete, Evercare Plan DH and SecureHorizons MedicareComplete, including Group Retiree Plans underwritten by Oxford Health Plans (NY/NJ/CT), Inc. (CMS Contract Numbers: H0752, H3107 and H3307)

For Commercial Members, refer to policy: Wireless Capsule Endoscopy for Commercial Plans.
Note:
Due to insufficient clinical evidence to support medical efficacy, Patency Capsule Testing (e.g., Given Agile Patency System or similar devices) for the treatment of gastrointestinal conditions will not be reimbursed by Oxford or by CMS. This service and/or device is not proven to be clinically effective and, therefore, is not considered to be medically necessary.


Conditions of Coverage
Benefit Type
General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
No
Authorization (Precertification always required for inpatient admission)
Yes
Precertification with MD Review
Yes
Site(s) of Service
(If not listed, MD Review required)
Outpatient, Office
Special Considerations
Precertification with Medical Director review or their Designee is required.

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