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38210 | T-cell depletion of harvest | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38212 | Rbc depletion of harvest | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0267 | Bone marrow or psc harvest | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0266 | Thawing + expansion froz cel | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0265 | Cryopresevation Freeze+stora | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0267 | Bone marrow or psc harvest | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
G0266 | Thawing + expansion froz cel | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
G0265 | Cryopresevation Freeze+stora | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
G0279 | TOMOSYNTHESIS MAMMO DX Injectable Drugs Not on Fee Schedule | HCPCS | 09/23/2014: Policy reviewed; description revised. Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | 09/23/2014: Policy reviewed; description revised. Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | 09/23/2014: Policy reviewed; description revised. Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. |
77063 | Screening 3D breast mammography | HCPCS | 09/23/2014: Policy reviewed; description revised. Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. |
G0279 | TOMOSYNTHESIS MAMMO DX Injectable Drugs Not on Fee Schedule | HCPCS | Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. |
77063 | Screening 3D breast mammography | HCPCS | Policy statement unchanged. 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. |
G0279 | TOMOSYNTHESIS MAMMO DX Injectable Drugs Not on Fee Schedule | HCPCS | 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. Policy statement unchanged. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. Policy statement unchanged. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. Policy statement unchanged. |
77063 | Screening 3D breast mammography | HCPCS | 02/23/2015: Added HCPCS code G0279 to the Code Reference section. 04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section. 07/13/2015: Code Reference section updated for ICD-10. 10/22/2015: Policy description updated regarding tomosynthesis systems. Policy statement unchanged. |
0204 | Psych/Detox | RC | 01/20/2016: Policy description updated. Policy statement unchanged. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
0206 | HC INTERMEDIATE ROOM AND CARE ISOLATION | RC | 01/20/2016: Policy description updated. Policy statement unchanged. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
0204 | Psych/Detox | RC | Policy statement unchanged. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
0206 | HC INTERMEDIATE ROOM AND CARE ISOLATION | RC | Policy statement unchanged. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
0204 | Psych/Detox | RC | 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
0206 | HC INTERMEDIATE ROOM AND CARE ISOLATION | RC | 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 6.01.53
This may not be a comprehensive list of procedure codes applicable to this policy. Unlisted diagnostic radiographic procedure
Digital breast tomosynthesis; unilateral
Digital breast tomosynthesis; bilateral
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) |
44799 | Unlisted px small intestine | HCPCS | 04/24/2014: Policy reviewed; description updated regarding FDA approval of devices. Policy statement unchanged. 12/31/2014: Code Reference section updated to revise the description of the following CPT code: 44799. Added the following new 2015 HCPCS code: G6021. 04/01/2015: Policy description updated regarding devices. |
44799 | Unlisted px small intestine | HCPCS | Policy statement unchanged. 12/31/2014: Code Reference section updated to revise the description of the following CPT code: 44799. Added the following new 2015 HCPCS code: G6021. 04/01/2015: Policy description updated regarding devices. Policy statements unchanged. |
44799 | Unlisted px small intestine | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT code: 44799. Added the following new 2015 HCPCS code: G6021. 04/01/2015: Policy description updated regarding devices. Policy statements unchanged. Policy guidelines updated to revise the definition of investigative. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS Level III contains alphanumeric codes that are assigned
by Medicaid state agencies to identify additional items
and services not included in levels I or II. These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. HIPAA does not replace the states' roles as primary regulators
of insurance. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. |
43644 | PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
S2083 | PR ADJUSTMENT GASTRIC BAND | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
S2082 | Lap adjustable gastric band | CPT | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43633 | Removal of stomach partial | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43847 | PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43645 | PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
S2085 | Laparoscop gastric bypass | CPT | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43848 | Revision gastroplasty | HCPCS | POLICY HISTORY1/1993: Approved by Medical Policy Advisory Committee (MPAC)
11/1998: Medical Management of Obesity approved by MPAC
8/1999: Revisions to Surgery for Morbid Obesity approved by MPAC
1/2000: Medical Management of Obesity and Surgery for Morbid Obesity policies merged; interim policy revisions
2/2000: Interim policy revisions approved by MPAC
3/22/2000: See POLICY EXCEPTIONS for First Chemical
9/14/2000: Long limb (>100 cm) gastric bypass procedures are investigational and not covered. See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. |
43644 | PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
S2083 | PR ADJUSTMENT GASTRIC BAND | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
S2082 | Lap adjustable gastric band | CPT | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43633 | Removal of stomach partial | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43847 | PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43645 | PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
S2085 | Laparoscop gastric bypass | CPT | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43848 | Revision gastroplasty | HCPCS | See Surgical Management
1/9/2001: See POLICY EXCEPTIONS for BancorpSouth
2/2/2001: See POLICY EXCEPTIONS for Mississippi Power
11/29/2001: See POLICY EXCEPTIONS for Ryder System, Incorporation
1/7/2002: Singing River (self insured group) will cover all 5 surgical procedures for morbid obesity added to POLICY EXCEPTIONS. 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." |
43644 | PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
S2083 | PR ADJUSTMENT GASTRIC BAND | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
S2082 | Lap adjustable gastric band | CPT | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43633 | Removal of stomach partial | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43847 | PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43645 | PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
S2085 | Laparoscop gastric bypass | CPT | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43848 | Revision gastroplasty | HCPCS | 2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. |
43644 | PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
S2083 | PR ADJUSTMENT GASTRIC BAND | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
S2082 | Lap adjustable gastric band | CPT | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
43847 | PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
43645 | PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
S2085 | Laparoscop gastric bypass | CPT | All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated. |
S2083 | PR ADJUSTMENT GASTRIC BAND | HCPCS | CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section. |
43774 | PR LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT | HCPCS | CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section. |
43888 | PR GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT | HCPCS | CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section. |
43770 | PR LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE | HCPCS | CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section. |
43886 | Revise gastric port open | HCPCS | CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. |
S9452 | Nutrition class | HCPCS | FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. |
S9452 | Nutrition class | HCPCS | Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. |
43846 | PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< | HCPCS | Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. |
43845 | PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM | HCPCS | Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21. |
S9452 | Nutrition class | HCPCS | Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21. |
43659 | HC UNLISTED LAPAROSCOPE PROC STOM | HCPCS | Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21. |
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