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E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
63660 | Revise/Remove Neuroelectrode | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95973 | Analyze neurostim complex | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0756 | Implantable pulse generator | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0758 | External RF transmitter | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0757 | Implantable RF receiver | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0756 | Implantable pulse generator | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0758 | External RF transmitter | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0757 | Implantable RF receiver | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0756 | Implantable pulse generator | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0758 | External RF transmitter | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0757 | Implantable RF receiver | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
87476 | LYME DISEASE PCR | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87477 | Lyme dis dna quant | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87475 | Lyme dis dna dir probe | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87476 | LYME DISEASE PCR | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87477 | Lyme dis dna quant | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87475 | Lyme dis dna dir probe | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
J0550 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0540 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87476 | LYME DISEASE PCR | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0530 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87477 | Lyme dis dna quant | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87475 | Lyme dis dna dir probe | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0550 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0540 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0530 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0550 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0540 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0530 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0580 | Penicillin g benzathine inj | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0560 | Penicillin g benzathine inj | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0580 | Penicillin g benzathine inj | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0560 | Penicillin g benzathine inj | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0580 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0560 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0580 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0560 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
95904 | Sense nerve conduction test | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. |
95903 | Motor nerve conduction test | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. |
95900 | Motor nerve conduction test | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. |
95904 | Sense nerve conduction test | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. |
95903 | Motor nerve conduction test | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. |
95900 | Motor nerve conduction test | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. |
0100 | Med-Surg | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | Given that lipedema is thought to affect 11% of the adult female population (7), it is vital that more research funding be allocated and larger scale studies take place. "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. |
0100 | Med-Surg | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | "LF14" or "EJ44" http://apps.who.int/classifications/icd11/browse/l-m/en#!http%3A%2F%2Fid.who.int%2Ficd%2Fentity%2F1172950828
Lipedema has a diagnostic code in "ICD-10 2017" but not "ICD-10 2016". We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. |
0100 | Med-Surg | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | We do not know when the US will move to "ICD-10 2017". The Germans have it in their version of "ICD-10 2016", "ICD-10 GM" now. E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. |
0100 | Med-Surg | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
0200 | INTENSIVE CARE UNIT - GENERAL CLASSIFICATION | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
0129 | ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - OTHER | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
1002 | HC ASAM LEVEL 3.7WM INPATIENT WITHDRAW MANAGEMENT | RC | E88.21 stage 1
E88.22 stage 2
E88.23 stage 3
Historical Alternate ICD-10 and ICD-9 codes: There is no clear-cut code, but some physicians use:
457.1 "lymphedema" if there is swelling component
Q82.0 "hereditary lymphedema" http://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q80-Q89/Q82-/Q82.0
E88.2 "Lipomatosis, not elsewhere classified"
Lipomatosis dolorosa of the legs
Painful column leg
Painful lipedema syndrome
Lipoedema (UK and Australian spelling)
Lipödem (German spelling)
There are >20 books that mention lipedema, see the list here http://fatdisorders.org/research/books
eLearning from RCGP in the UK
Therapists and some physicians
http://www.chirocredit.com/courses/index.php?catid=131&pid=20 then scroll to Lymphology 101; $18
http://www.nursingcenter.com/lnc/CEArticle?an=00129334-201002000-00010&Journal_ID=54015&Issue_ID=965181 ; $24.95
For Physical Therapists
http://ce.todayinpt.com/course/pt07/lipedema-often-confused-with-lymphedema/ ; $19
There are >160 papers on lipedema listed on our site here: http://fatdisorders.org/research/lipedema-lipoedema-research-papers
Back to top
1) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004; 57(3):282-286
2) http://www.tillysmidt.nl/LIPEDEMA%20%20Englisch%20for%20Lipoedeem.htm, adapted from this site
3) Todd, Marie, Lipoedema: presentation and management. Chronic Oedema, 2010; 10-16
4) Schmeller W, Meier-Vollrath I, Chapter 7 Lipedema, http://www.hanse-klinik.com/englisch/Lipoedema.pdf
5) Allen E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat legs and edema. |
00100 | ANESTH SALIVARY GLAND | CPT | A Quick Review of CPT Codes and ICD-10 Codes
CPT stands for Current Procedural Terminology and are published by the American Medical Association. Ranging from 00100 to 99499, the CPT codes are used to describe medical, surgical, and diagnostic services and procedures. Medical professionals like Physical Therapists use CPT codes to classify the treatment of diagnoses. |
00100 | ANESTH SALIVARY GLAND | CPT | A Quick Review of CPT Codes and ICD-10 Codes
CPT stands for Current Procedural Terminology and are published by the American Medical Association. Ranging from 00100 to 99499, the CPT codes are used to describe medical, surgical, and diagnostic services and procedures. Medical professionals like Physical Therapists use CPT codes to classify the treatment of diagnoses. ICD-9 Codes (International Classification of Diseases 9th edition) are used to classify signs, symptoms, injuries, diseases, and conditions. |
00100 | ANESTH SALIVARY GLAND | CPT | A Quick Review of CPT Codes and ICD-10 Codes
CPT stands for Current Procedural Terminology and are published by the American Medical Association. Ranging from 00100 to 99499, the CPT codes are used to describe medical, surgical, and diagnostic services and procedures. Medical professionals like Physical Therapists use CPT codes to classify the treatment of diagnoses. ICD-9 Codes (International Classification of Diseases 9th edition) are used to classify signs, symptoms, injuries, diseases, and conditions. The idea is that the CPT code (treatment, service, procedure) matches up logically with the ICD-10 code (the symptom, injury, etc.). |
00100 | ANESTH SALIVARY GLAND | CPT | Ranging from 00100 to 99499, the CPT codes are used to describe medical, surgical, and diagnostic services and procedures. Medical professionals like Physical Therapists use CPT codes to classify the treatment of diagnoses. ICD-9 Codes (International Classification of Diseases 9th edition) are used to classify signs, symptoms, injuries, diseases, and conditions. The idea is that the CPT code (treatment, service, procedure) matches up logically with the ICD-10 code (the symptom, injury, etc.). If the CPT code doesn’t support the ICD-10 code, you’ll have a problem – and you’ll likely have trouble getting reimbursed. |
00216 | ANESTH HEAD VESSEL SURGERY | CPT | For the procedure, we’d code 23140 for “excision or curretage of bone cyst or benign tumor, humerus; with autograft (includes obtaining the graft).” Since the procedure was completed but not fully successful, we’d add the -52 modifier, for reduced services, to the code, and we’d end up with 23140-52. Physical Status Modifier (for Anesthesia)
Anesthesia procedures have their own special set of modifiers, which are simple and correspond to the condition of the patient as the anesthesia is administered. These codes are:
- P1 – a normal, healthy patient
- P2 – a patient with mild systemic disease
- P3 – a patient with severe systemic disease
- P4 – a patient with severe systemic disease that is a constant threat to life
- P5 – a moribund patient who is not expected to survive without the operation
- P6 – a declared brain-dead patient whose organs are being removed for donor purposes
As we said, these are relatively straightforward, but let’s look at an example that will also use some of the CPT modifiers we learned just a minute ago. Let’s return to that angioplasty example. The patient needs to be anesthetized before undergoing this procedure, so we turn to the Anesthesia section of the CPT codebook and find the code 00216 for “vascular procedures.” Now, kidney problems notwithstanding, our patient is in good health, so we’d add the –P1 modifier to this anesthesia code, and end up with 00216-P1. |
00216 | ANESTH HEAD VESSEL SURGERY | CPT | These codes are:
- P1 – a normal, healthy patient
- P2 – a patient with mild systemic disease
- P3 – a patient with severe systemic disease
- P4 – a patient with severe systemic disease that is a constant threat to life
- P5 – a moribund patient who is not expected to survive without the operation
- P6 – a declared brain-dead patient whose organs are being removed for donor purposes
As we said, these are relatively straightforward, but let’s look at an example that will also use some of the CPT modifiers we learned just a minute ago. Let’s return to that angioplasty example. The patient needs to be anesthetized before undergoing this procedure, so we turn to the Anesthesia section of the CPT codebook and find the code 00216 for “vascular procedures.” Now, kidney problems notwithstanding, our patient is in good health, so we’d add the –P1 modifier to this anesthesia code, and end up with 00216-P1. Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
CPT modifiers are also used in ambulatory surgery centers (ASC). These hospital outpatient facilities specialize in procedures where the patient leaves the same day. |
00216 | ANESTH HEAD VESSEL SURGERY | CPT | Let’s return to that angioplasty example. The patient needs to be anesthetized before undergoing this procedure, so we turn to the Anesthesia section of the CPT codebook and find the code 00216 for “vascular procedures.” Now, kidney problems notwithstanding, our patient is in good health, so we’d add the –P1 modifier to this anesthesia code, and end up with 00216-P1. Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
CPT modifiers are also used in ambulatory surgery centers (ASC). These hospital outpatient facilities specialize in procedures where the patient leaves the same day. Note that there may be some overlap or contradiction with the set of HCPCS modifiers, which we’ll cover in more depth later on. |
1999 | ANESTHESIOLOGY GROUP | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
36511 | PR THERAPEUTIC APHERESIS WHITE BLOOD CELLS | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
36513 | PR THERAPEUTIC APHERESIS PLATELETS | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
36512 | PR THERAPEUTIC APHERESIS RED BLOOD CELLS | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
36521 | USE 36516 | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
36520 | SEE 36511-36512 | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36511 | PR THERAPEUTIC APHERESIS WHITE BLOOD CELLS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36513 | PR THERAPEUTIC APHERESIS PLATELETS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36512 | PR THERAPEUTIC APHERESIS RED BLOOD CELLS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36521 | USE 36516 | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36520 | SEE 36511-36512 | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
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