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Wiki Prostate Artery Embolization

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geiser35

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Stewartstown, PA
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Is anyone having difficulties with getting the 37243 (PAE) with N40.1 and R31.0 paid by GHI/Emblem in New York? The denial states, "Not deemed reasonable/necessary for reported diagnosis code as per the CMS National Coverage Determination Policy." The patient doesn't have a tumor. There aren't any LCD for CMS for NY. ZHealth recommends the 37243, but they did have one Q&A where the carrier suggested the 37242 since the pt's records didn't contain documentation of a prostatic or other pelvic tumor, any organ ischemia or infarction. So, Dr. Z suggested to call the payor to discuss. Has anyone had any dealings with any carriers over the 37243 vs 37242 for PAE cases? Thank you.

 
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