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L8628 | Cochlear implant, external controller component, replacement | HCPCS | ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. |
L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | HCPCS | ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. |
L8627 | Cochlear implant, external speech processor, component, replacement | HCPCS | 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines. |
L8628 | Cochlear implant, external controller component, replacement | HCPCS | 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines. |
L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | HCPCS | 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | Medically necessary policy statement updated to make correction: "100 HZ" updated to "1000 HZ." Policy Guidelines section updated regarding cochlear ossification and to add medically necessary and investigative definitions. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.05
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | 04/12/2010: Description section revised to add the four oncologic applications of PET Scanning; Policy section revised to add indications considered medically necessary for Melanoma, Lymphoma, lung; colorectal; pancreatic; head & neck; esophageal; breast; ovarian and testicular cancers. Added indications considered medically necessary for differentiated thyroid and cervical cancers; added prostate cancer and cancer surveillance as investigational for all indications. Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Added indications considered medically necessary for differentiated thyroid and cervical cancers; added prostate cancer and cancer surveillance as investigational for all indications. Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. Corrected typo to change 235.4 to 236.4. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. Corrected typo to change 235.4 to 236.4. Added 199.1, 209.20, 209.72, and 233.6 to the Covered Codes table. |
99184 | PR INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0882 | Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7516 | Injection, cyclosporine, 250 mg | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
97814 | PR ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J3230 | Injection, chlorpromazine hcl, up to 50 mg | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7502 | ZZ IMS TEMPLATE | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0885 | INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38207 | PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0153 | INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7515 | ZZ IMS TEMPLATE | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38241 | Transplt autol hct/donor | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0887 | INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38240 | Transplt allo hct/donor | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0881 | INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
Q4081 | Injection, epoetin alfa, 100 units (for esrd on dialysis) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0888 | Injection, epoetin beta, 1 microgram, (for non esrd use) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7604 | N-ACETYL-L-CYSTEINE POWDER | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
97810 | PR ACUPUNCTURE 1/> NDLES W/O ELEC STIMJ INIT 15 MIN | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38242 | Transplt allo lymphocytes | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J3475 | NEONATAL TPN 2-IN-1 (ENTERPRISE) | HCPCS | Additional strategies that may be useful as adjuncts to hypothermia include …. Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
99184 | PR INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0882 | Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7516 | Injection, cyclosporine, 250 mg | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
97814 | PR ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J3230 | Injection, chlorpromazine hcl, up to 50 mg | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7502 | ZZ IMS TEMPLATE | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0885 | INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38207 | PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0153 | INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7515 | ZZ IMS TEMPLATE | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38241 | Transplt autol hct/donor | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0887 | INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38240 | Transplt allo hct/donor | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0881 | INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
Q4081 | Injection, epoetin alfa, 100 units (for esrd on dialysis) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J0888 | Injection, epoetin beta, 1 microgram, (for non esrd use) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J7604 | N-ACETYL-L-CYSTEINE POWDER | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
97810 | PR ACUPUNCTURE 1/> NDLES W/O ELEC STIMJ INIT 15 MIN | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
38242 | Transplt allo lymphocytes | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
J3475 | NEONATAL TPN 2-IN-1 (ENTERPRISE) | HCPCS | Administration of growth factors (monosialo-gangliosides, brain derived growth factor), nitric oxide synthase inhibitors, and blockers of apoptosis”. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|99184||Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling|
|CPT codes not covered for indications listed in the CPB:|
|38204 - 38205, 38207 - 38215, 38230, 38240, 38242||Bone marrow or stem cell services/procedures-allogenic|
|38241||Hematopoietic progenitor cell (HPC); autologous transplantation|
|97810 - 97814||Acupuncture|
|99481||Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|99482||Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)|
|HCPCS codes not covered for indications listed in the CPB:|
|There are no specific codes for allopurinol:|
|J0153||Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)|
|J0881||Injection, darbepoetin alfa, 1 microgram (non-ESRD use)|
|J0882||Injection, darbepoetin alfa, 1 microgram (for ESRD use)|
|J0885||Injection, epoetin alfa, (for non-ESRD use), 1000 units|
|J0887 - J0888||Injection, epoetin beta, 1 microgram|
|J3230||Injection, chlorpromazine HCI, up to 50 mg|
|J3475||Injection, magnesium sulfate, per 500 mg|
|J7502||Cyclosporine, oral, 100 mg|
|J7515||Cyclosporine, oral, 25 mg|
|J7516||Cyclosporine, parenteral, 250 mg|
|J7604||Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram|
|Q4081||Injection, epoetin alfa, 100 units (for ESRD on dialysis)|
|ICD-10 codes covered if selection criteria are met:|
|P91.62||Moderate hypoxic ischemic encephalopathy [HIE]|
|P91.63||Severe hypoxic ischemic encephalopathy [HIE]| |
48154 | PR PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY | HCPCS | R.A. Fischer Company will bill your insurance company if you have prior authorization and approval. Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | R.A. Fischer Company will bill your insurance company if you have prior authorization and approval. Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. |
E1399 | ITEM 6664 | CPT | R.A. Fischer Company will bill your insurance company if you have prior authorization and approval. Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. |
48154 | PR PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY | HCPCS | Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. Please visit our Insurance page for more information. |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. Please visit our Insurance page for more information. |
E1399 | ITEM 6664 | CPT | Otherwise, patients typically purchase the device and then obtain reimbursement from their health plan. Your insurance company may require one or more of the following codes to process a claim:
- ICD-10 Codes:
- L74.5 – Focal Hyperhidrosis
- L74.51 – Primary Focal Hyperhidrosis
- L74.510 – Axilla
- L74.511 – Face
- L74.512 – Palms
- L74.513 – Soles
- L74.519 – Unspecified
- L74.52 – Secondary Focal Hyperhidrosis
- HCPCS or HIC/PIC Code: E1399 “Tapwater Iontophoresis”
- CPT Code: 97033 (only for use when billing treatments done in office)
FEIN Number (A.R. Hinkel Co. dba R.A. Fischer Co.): 95-4063106
NPI Number (National Provider ID for Insurance): 1174815484
Can Fischer help me find out if my insurance will cover the cost of a unit? Yes, we are happy to help you find out about insurance coverage through your carrier. Please visit our Insurance page for more information. |
U0002 | HC Sars-Cov-2 Naa Coronavirus | HCPCS | Knowing your state laws and payer rules is important in this instance. (See resources for AAP fact sheet on coding for telehealth services and help in navigating your state laws on telehealth services.) Advocacy and payment
The AAP is monitoring health plan carrier uptake of the new Healthcare Common Procedure Coding System (HCPCS) Level II codes: U0001 and U0002. Per CMS, the Medicare claims processing system will be able to accept this code for payment as of April 1 for dates of service on or after Feb. 4, 2020. The Academy sent inquiries to the largest national carriers (Aetna, Anthem, Cigna, Humana and UnitedHealthcare) to ascertain their coverage policies. |
U0001 | HC NOVEL CORONAVIRUS REALT TIME PCR | HCPCS | Knowing your state laws and payer rules is important in this instance. (See resources for AAP fact sheet on coding for telehealth services and help in navigating your state laws on telehealth services.) Advocacy and payment
The AAP is monitoring health plan carrier uptake of the new Healthcare Common Procedure Coding System (HCPCS) Level II codes: U0001 and U0002. Per CMS, the Medicare claims processing system will be able to accept this code for payment as of April 1 for dates of service on or after Feb. 4, 2020. The Academy sent inquiries to the largest national carriers (Aetna, Anthem, Cigna, Humana and UnitedHealthcare) to ascertain their coverage policies. |
U0002 | HC Sars-Cov-2 Naa Coronavirus | HCPCS | (See resources for AAP fact sheet on coding for telehealth services and help in navigating your state laws on telehealth services.) Advocacy and payment
The AAP is monitoring health plan carrier uptake of the new Healthcare Common Procedure Coding System (HCPCS) Level II codes: U0001 and U0002. Per CMS, the Medicare claims processing system will be able to accept this code for payment as of April 1 for dates of service on or after Feb. 4, 2020. The Academy sent inquiries to the largest national carriers (Aetna, Anthem, Cigna, Humana and UnitedHealthcare) to ascertain their coverage policies. The carriers will offer the test with no patient out-of-pocket expense, and as of press time, Humana replied that it will follow CMS with retroactive coverage to Feb. 4, 2020. |
U0001 | HC NOVEL CORONAVIRUS REALT TIME PCR | HCPCS | (See resources for AAP fact sheet on coding for telehealth services and help in navigating your state laws on telehealth services.) Advocacy and payment
The AAP is monitoring health plan carrier uptake of the new Healthcare Common Procedure Coding System (HCPCS) Level II codes: U0001 and U0002. Per CMS, the Medicare claims processing system will be able to accept this code for payment as of April 1 for dates of service on or after Feb. 4, 2020. The Academy sent inquiries to the largest national carriers (Aetna, Anthem, Cigna, Humana and UnitedHealthcare) to ascertain their coverage policies. The carriers will offer the test with no patient out-of-pocket expense, and as of press time, Humana replied that it will follow CMS with retroactive coverage to Feb. 4, 2020. |
G6015 | Radiation tx delivery imrt | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77386 | HC IMRT COMPLEX | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77385 | HC IMRT SIMPLE | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6015 | Radiation tx delivery imrt | HCPCS | Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. |
77386 | HC IMRT COMPLEX | HCPCS | Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. |
77385 | HC IMRT SIMPLE | HCPCS | Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. |
G6015 | Radiation tx delivery imrt | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. |
77386 | HC IMRT COMPLEX | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. |
77385 | HC IMRT SIMPLE | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. |
S0145 | Peg interferon alfa-2A/180 | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [ie, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. |
S0146 | Peg interferon alfa-2b/10 | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [ie, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. |
J9214 | interferon alfa-2b per 1000000 Units | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [ie, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. |
J8499 | ZONISAMIDE 2.5ML 50MG 2.5ML SPPO | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [ie, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. |
J9213 | Interferon alfa-2a inj | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [ie, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. |
S0145 | Peg interferon alfa-2A/180 | HCPCS | 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. |
S0146 | Peg interferon alfa-2b/10 | CPT | 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. |
J9214 | interferon alfa-2b per 1000000 Units | HCPCS | 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. |
J8499 | ZONISAMIDE 2.5ML 50MG 2.5ML SPPO | HCPCS | 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. |
J9213 | Interferon alfa-2a inj | HCPCS | 11/19/2003: Approved by external gastroenterology consultants
12/18/2003: Code Reference section completed
11/02/2005: Description section updated, Off Label Uses and Renal carcinoma deleted. Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. |
S0145 | Peg interferon alfa-2A/180 | HCPCS | Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. |
S0146 | Peg interferon alfa-2b/10 | CPT | Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. |
J9214 | interferon alfa-2b per 1000000 Units | HCPCS | Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. |
J8499 | ZONISAMIDE 2.5ML 50MG 2.5ML SPPO | HCPCS | Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. |
J9213 | Interferon alfa-2a inj | HCPCS | Policy section updated; changed preferred provider to CuraScript. 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. |
S0145 | Peg interferon alfa-2A/180 | HCPCS | 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. Dosing Genotype 1, 2 and 3 deleted. |
S0146 | Peg interferon alfa-2b/10 | CPT | 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. Dosing Genotype 1, 2 and 3 deleted. |
J9214 | interferon alfa-2b per 1000000 Units | HCPCS | 11/4/2005: Code Reference section updated, HCPCS codes J8499, J9213, J9214 moved from the CPT4 code section in the table to the HCPCS code section, a deletion date of 6/30/2005 was added to codes J9213 and J9214; HCPCS codes S0145 and S0146 added with an effective date of 7/1/2005; the Non-Covered Codes table was deleted from the policy. 11/2005: Approved by Pharmacy & Therapeutic (P & T) Committee. 6/29/2006: CuraScript fax number changed from 1-877-462-6234 to 1-866-239-5502
5/5/2008: Ribavirin dosing information updated
01/01/2009: CuraScript preferred provider information removed. BCBSMS information added
12/29/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
4/14/2009: Policy statement updated to reflect retreatment guidelines
8/18/2009: Policy updated: Policy statement updated to include statement Peg-Intron® may be considered medically necessary only after failed treatment (nonresponder or relapser) with Pegasys®. Dosing Genotype 1, 2 and 3 deleted. |
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