956 Form

Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease Prior Authorization Request Form #956

Medical Policy #920 Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease (956) using Authorization Manager.

For out of network providers: Requests should still be faxed to 888-282-0780.

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Place of Service: Outpatient  Inpatient 

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

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  MAGNETIC ESOPHAGEAL SPHINCTER AUGMENTATION

  Please check off if the procedure being requested is the following:
  Magnetic esophageal sphincter augmentation.

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  Please check off if the patient meets ALL of the following criteria: Patient has a history of severe GERD for ≥1 year with daily symptoms, AND

   Patient has tried and failed optimal non-surgical management of symptoms, including lifestyle modification, weight loss (if indicated), and daily proton pump inhibitor use for ≥ 6 months, AND

   Patient has proven gastroesophageal reflux by either endoscopy, ambulatory pH monitoring, AND
  Patient has evidence of adequate peristalsis by manometry or barium esophagram

   None of the following contraindications are present:

   • Morbid obesity (BMI >35)

   • Suspected or known allergies to metals such as iron, nickel, titanium, or stainless steel

   • Grade C or D (LA classification) esophagitis

   • Scleroderma

   • Esophageal stricture or gross esophageal anatomic abnormalities

   • Suspected or confirmed esophageal or gastric cancer

   • Prior esophageal or gastric surgery or endoscopic intervention.

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  TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) (IE, ESOPHYX®)

  Please check off if the procedure being requested is the following:
  Transoral incisionless fundoplication (TIF) (ie, EsophyX®).

  

  Please check off if the patient meets ALL of the following criteria: Patient has a history of severe GERD for ≥1 year with daily symptoms, AND

   Patient has tried and failed optimal non-surgical management of symptoms, including lifestyle modification, weight loss (if indicated), and daily proton pump inhibitor use for ≥ 6 months, AND

   Patient has proven gastroesophageal reflux by either endoscopy, ambulatory pH monitoring, or barium esophagram, AND

   None of the following contraindications are present:

   • Hiatal hernia >2cm in axial height and >2cm in greatest transverse dimension

   • Morbid obesity (BMI >35)

   • Esophagitis grade C or D

   • Barrett's esophagus > 2 cm

   • Non-healing esophageal ulcer

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  • Fixed esophageal stricture or narrowing

   • Portal hypertension and/or varices

   • Active gastro-duodenal ulcer disease

   • Gastric outlet obstruction or stenosis

   • Gastroparesis

   • Prior esophageal surgery

   • Scleroderma

   • Suspected or confirmed esophageal or gastric cancer.

  

  Note: Transesophageal radiofrequency to create submucosal thermal lesions of the gastroesophageal junction (ie, the Stretta® procedure) is considered INVESTIGATIONAL as a treatment of gastroesophageal reflux disease.

  Note: Endoscopic submucosal implantation of a prosthesis or injection of a bulking agent (eg, polymethylmethacrylate beads, zirconium oxide spheres) is INVESTIGATIONAL as a treatment of gastroesophageal reflux disease.

  CPT CODES/ HCPCS CODES

  Please check off all the relevant CPT codes:
  43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed  43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed 

  Providers should enter the relevant diagnosis code(s) below: Code Description

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  Providers should enter other relevant code(s) below: Code Description

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