Passport Health Plan by Molina Healthcare policy

Perirectal Spacer for Prostate Radiotherapy

Perirectal Spacer for Prostate Radiotherapy is a public Passport Health Plan by Molina Healthcare policy (policy 425). It lists 1 CPT or HCPCS code. Not a coverage decision; the payer's own document governs.

View the original policy (PDF) ↗

Payer: Passport Health Plan by Molina Healthcare
Policy number: 425
Line of business: Commercial
Source: www.molinaclinicalpolicy.com

Codes in this policy

The CPT and HCPCS codes the policy names. A policy can name a code it excludes.

Code	Other Passport Health Plan by Molina Healthcare policies
55874	Policies naming 55874

All Passport Health Plan by Molina Healthcare policies

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.