RETIRED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

CIGNA Government Services
Contractor Number ^{back to top}
05440
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L6386

LCD Title ^{back to top}
Transurethral Microwave Thermotherapy

Contractor's Determination Number ^{back to top}
ID 97-005

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
. Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations. . Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Primary Geographic Jurisdiction ^{back to top}
Tennessee

Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 09/15/1997

Original Determination Ending Date ^{back to top}
08/28/2009

Revision Effective Date ^{back to top}
For services performed on or after 11/01/2005

Revision Ending Date ^{back to top}
08/28/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Thermotherapy is currently covered by Medicare only for treatment of outlet obstruction caused by benign prostatic hyperplasia.

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

53850 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE THERMOTHERAPY

ICD-9 Codes that Support Medical Necessity ^{back to top}

600.00	HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS)
600.01	HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.10	NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION
600.11	NODULAR PROSTATE WITH URINARY OBSTRUCTION
600.20	BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.21	BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
600.3	CYST OF PROSTATE
600.90	HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS)
600.91	HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS)

Diagnoses that Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

General Information

Documentation Requirements ^{back to top}

The patient’s medical record should document the benign prostatic hyperplasia and the severity of the outlet obstruction.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Sources of Information and Basis for Decision ^{back to top}

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the carrier, or the Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee, which includes specialists from various fields.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from .

Start Date of Comment Period ^{back to top}

03/12/1997

End Date of Comment Period ^{back to top}

Start Date of Notice Period ^{back to top}

08/01/1997

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

Addition of CPT code: 53850

This LCD was converted from an LMRP on 5/10/2004

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

Changed date of retirement from 8/31/09 to 8/28/09 per CMS CR6436

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

09/25/2008

Medicare Coverage Database

LCD for Transurethral Microwave Thermotherapy (L6386)