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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.60 Radiation Therapy : 9.2.60.2 Stereotactic Radiosurgery

9.2.60.2
9.2.60.2.1
The following procedure codes are a benefit of Texas Medicaid with prior authorization and documentation of medical necessity:
 
Prior authorization requirements for stereotactic radiosurgery and stereotactic body radiation therapy may include, but are not limited to, diagnoses indicating one of the following medical conditions:
Stereotactic radiosurgery and stereotactic body radiation therapy are considered investigational and not a benefit of Texas Medicaid for all other indications including, but not limited to, epilepsy, chronic pain, and pancreatic adenocarcinoma.
Prior authorization requirements for proton beam (procedure codes 77520, 77522, 77523, 77525, and S8030) and helium ion radiosurgery (procedure codes 77422 and 77423) may include, but are not limited to, diagnoses indicating one of the following medical conditions:
Prior authorization for neutron beam radiosurgery may be considered for malignant neoplasms of the salivary gland.
Prior authorization requirements for procedure code 77399 include, but are not limited to, diagnosis, documentation of medical necessity, a specific description of the procedure to be performed, and an indication that the procedure would not be covered by a more specific procedure code.
Stereotactic radiosurgery and stereotactic body radiation therapy will not be prior authorized for clients with metastatic disease and a projected life span of less than six months or for clients with widespread cerebral or extracranial metastasis that is not responsive to systemic therapy.
9.2.60.2.2
In the following table, the procedure codes in Column A may be reimbursed when at least one corresponding procedure code from Column B has been paid to the same provider for the same date of service:
 
Procedure codes 61796 and 63620 must not be billed more than once per course of treatment.
Procedure codes 61797 and 61799 must not be billed more than once per lesion, and may only be billed up to four times for the entire course of treatment, regardless of the number of lesions treated.
Procedure code 63621 may only be billed up to two times for the entire course of treatment, regardless of the number of lesions treated.

Texas Medicaid & Healthcare Partnership
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