Prior Authorization Required

Prior authorization is required for MRgFUS procedures that meet medically necessary indications. Verify member benefit coverage and obtain any required prior authorization from Capital Bluecross before scheduling or performing MRgFUS.

• Prior authorization applies to covered procedure codes: 0947T, 61715, 76498, C9734.
• Not all Capital Blue Cross products/programs are covered by this policy; verify product applicability before requesting authorization.

Investigational Uses — Denial Risk

Procedures and uses outside the policy’s specified medically necessary indications are considered investigational and may be denied. Claims for investigational procedure codes will not be covered.

• Investigational procedure codes (not covered): 0071T, 0072T.
• MRgFUS considered investigational for indications such as uterine fibroids, treatment of other tumors (eg, brain, prostate, breast, desmoid), and medication-refractory tremor-dominant Parkinson disease unless otherwise noted as FDA-approved and specified in this policy.

Device and Model Documentation

Document device and model information in the medical record when submitting prior authorization requests and claims. Include the ExAblate system model when applicable to support medical necessity and coding.

• Record device details (e.g., ExAblate System Model 2000/2100/2100 VI, ExAblate Neuro, ExAblate Model 4000, Exablate Prostate) on the request/claim where relevant.
• Include FDA product codes (NRZ, POH, PLP) as appropriate in clinical documentation.

Benefit and Medical Necessity Verification

Final claim payment is subject to member eligibility, benefits, and a determination that the service was medically necessary and appropriate per the member’s benefit contract.

• Verify member eligibility and benefit limitations prior to treatment.
• Authorization or medical necessity determinations do not guarantee payment; claims are processed according to the member’s contract terms.

Prior Conservative/Standard Therapy Required

Prior conservative or standard therapies must have been tried and failed, or be contraindicated, for the covered indications before MRgFUS will be considered medically necessary.

• Metastatic bone pain: patients should have failed or be not candidates for external-beam radiotherapy and prior conservative measures (eg, analgesics, bisphosphonates, corticosteroids) where appropriate.
• Essential tremor: patients should be medicine-refractory (failed or intolerant to beta-blockers or anticonvulsant agents) before considering MRgFUS.

Confirm program/product applicability for prior authorization

This policy applies only to certain Capital Blue Cross programs and products; verify benefit applicability and any prior authorization requirements with the appropriate product administrator before proceeding with MRgFUS.

Prior authorization implied/required for covered MRgFUS codes

When billing MRgFUS with codes 0947T, 61715, 76498, or C9734, obtain any required prior authorization and ensure the service meets medical necessity, as coverage is only for medically necessary services and subject to benefit determination.

• Covered codes: 0947T, 61715, 76498, C9734
• Services are subject to medical necessity review and benefit limits

Confirm MRI compatibility and thermometry capability for MRgFUS

MRI compatibility and online thermometric imaging are required during MRgFUS; ensure the ultrasound equipment used is designed to be compatible with the MRI magnet prior to scheduling and document compatibility.

• MRI provides online thermometric imaging (temperature mapping) during treatment
• Confirm the ultrasound equipment is compatible with the MR magnet and document this