Wiki Sacroplasty 0201t medicare help pls

[colham478]

Hi, Hoping someone who codes for spinal surgeons or radiologists can assist me with a dilema. We did a Sacroplasty procedure -code 0201T on a patient recently and I know that it is not usually a covered service by Medicare;however I thought I would call our MAC (cgs) as there are not LCD'S listed for this procedure, it just says : see local MAC for coverage information. I called our local and s/w someone who told me basically to "check my CPT book"... I said-hmmmm..... So after about 20 minutes she finally told me that I should just send my claim and "see what happens" She said they my deny if the claim and doc doesn't meet medical necessity... So I asked her what is considered Medical Necessity for Sacroplasty and once again she refered me to my CPT book. hmmmmm.... She also said that Sacroplasty (0201T) was not considered experimental by medicare and is payable.

After that background, my true question is: Is a Sacroplasty considered experimental by Medicare?? Or has anyone gotten it paid for one? It's a tech code so my hopes are not high and I really dont' want to take the word of someone who thinks coverage and benefit information along with medical necessity requirements are located in the CPT book. (but that would be a wonderful idea! )

 

[semmett]

For our MAC which is NGS in Illinois, Category III codes (T codes) are not covered if there is no LCD established for them. They will also be denied for being considererd experimental procedures, not widely accepted by the medical community, not safe, etc,etc. The LCD used to deny these codes here is L25275. You may try to appeal it with the operative report and any patient specifics for medical necessity. I've also pushed back with the CPT guidelines which state that "if a Category III code is available, this code must be reported instead of a Category I unlisted code" and that "the purpose of these codes is to allow physicians and other qualified health care profesionals to identify emerging technology, services and procedures..." Good luck. Hope this helps.