016.06.04 Ark. Code R. 086

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.04-086 - Official Notice DMS-2004-L-19, DMS-2004-R-21

Enterra Therapy for Treatment of Gastroparesis

Effective for dates of service on and after March 1, 2005, Arkansas Medicaid will cover Enterra, implantable neurostimulator therapy.

A. Coverage of Enterra therapy is limited to individuals ages 18 through 69 with diabetic and idiopathic gastroparesis (diagnosis codes 536.3 and 250.6).

1. Service will include the implantable neurostimulator electrode(s) and the neurostimulator pulse generator.

2. Implantation procedures for neurostimulator pulse generator and the neurostimulator electrodes are covered as inpatient surgical procedures.

a. The surgical procedures require prior authorization (PA) by Arkansas Foundation for Medical Care, Inc. (AFMC). Refer to your provider manual for AFMC PA request procedures.

b. An approval letter from the Institutional Review Board is required. Patient's record must include documentation that further total parental nutrition (TPN) therapy is not an option.

3. Procedure for revision or removal of the peripheral neurostimulator electrodes does not require PA, but claim will be manually reviewed prior to reimbursement.

B. The following procedure codes must be used when filing claims.

S2213 - Implantation of gastric electrical stimulation 64555 - Implantation of peripheral neurostimulator electrodes

64595 - Revision or removal of the peripheral neurostimulator electrodes

Claims filed for procedure codes S2213 and 64555 must include a prior authorization number.

Procedure code 64595 does not require prior authorization but claim must be filed on paper with operative report attached.

All paper claims require a type of service code 2 for surgery and, if necessary, type of service code 8 for assistant surgeon.

Thank you for your participation in the Arkansas Medicaid Program.

Roy Jeffus, Director

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 and 1-877-708 -8191. Both telephone numbers are voice and TDD.

If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1 - 800-457-4454, or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www, medicaid, state, or. us.

016.06.04 Ark. Code R. 086

5/9/2005