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36511 | PR THERAPEUTIC APHERESIS WHITE BLOOD CELLS | 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. |
36513 | PR THERAPEUTIC APHERESIS PLATELETS | 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. |
36512 | PR THERAPEUTIC APHERESIS RED BLOOD CELLS | 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. |
36521 | USE 36516 | 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. |
36520 | SEE 36511-36512 | 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. |
36522 | PR PHOTOPHERESIS EXTRACORPOREAL | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
86960 | HC VOL REDUC BLD/PRD EA UN | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36516 | PR THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36515 | Apheresis adsorp/reinfuse | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36522 | PR PHOTOPHERESIS EXTRACORPOREAL | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
86960 | HC VOL REDUC BLD/PRD EA UN | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
36516 | PR THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
36515 | Apheresis adsorp/reinfuse | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
88145 | Cytopath, c/v, thin lyr sel | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0148 | Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
87620 | Hpv dna dir probe | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88174 | Cytopath c/v auto in fluid | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88148 | Cytopath c/v auto rescreen | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0143 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88153 | Cytopath c/v redo | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
87621 | Hpv dna amp probe | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
87622 | Hpv dna quant | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88147 | Cytopath c/v automated | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0124 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88165 | Cytopath tbs c/v redo | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
P3000 | Screen pap by tech w md supv | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0123 | SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0145 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
G0147 | Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
P3001 | Screening pap smear by phys | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88164 | HC CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88144 | Cytopath, c/v, thin lyr redo | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88175 | PAP | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. |
88145 | Cytopath, c/v, thin lyr sel | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0148 | Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
87620 | Hpv dna dir probe | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88174 | Cytopath c/v auto in fluid | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88148 | Cytopath c/v auto rescreen | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0143 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88153 | Cytopath c/v redo | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
87621 | Hpv dna amp probe | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
87622 | Hpv dna quant | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88147 | Cytopath c/v automated | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0124 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88165 | Cytopath tbs c/v redo | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
P3000 | Screen pap by tech w md supv | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0123 | SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0145 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
G0147 | Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
P3001 | Screening pap smear by phys | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88164 | HC CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88144 | Cytopath, c/v, thin lyr redo | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
88175 | PAP | HCPCS | POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. |
87622 | Hpv dna quant | HCPCS | Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. |
P3000 | Screen pap by tech w md supv | HCPCS | Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. |
88174 | Cytopath c/v auto in fluid | HCPCS | Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. |
P3001 | Screening pap smear by phys | HCPCS | Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. |
88175 | PAP | HCPCS | Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. |
87622 | Hpv dna quant | HCPCS | CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. |
P3000 | Screen pap by tech w md supv | HCPCS | CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. |
88174 | Cytopath c/v auto in fluid | HCPCS | CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. |
P3001 | Screening pap smear by phys | HCPCS | CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. |
88175 | PAP | HCPCS | CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. |
87622 | Hpv dna quant | HCPCS | 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | HCPCS | 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. |
87622 | Hpv dna quant | HCPCS | 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | HCPCS | 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. |
87622 | Hpv dna quant | HCPCS | The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | HCPCS | The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." |
87622 | Hpv dna quant | HCPCS | CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." 05/01/2011: The policy statement regarding HPV testing in conjunction with Pap smears was revised to state that HPV testing may be considered medically necessary only if there is an abnormal Pap smear documented in the medical record. |
G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | HCPCS | CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." 05/01/2011: The policy statement regarding HPV testing in conjunction with Pap smears was revised to state that HPV testing may be considered medically necessary only if there is an abnormal Pap smear documented in the medical record. |
E0751 | PULSE GENERATOR OR RECEIVER | 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. 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. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | 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. 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. |
63690 | -1 | 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. 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. |
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. 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. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | 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. 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. |
E0753 | NEUROSTIMUL ELECTRODES/LEADS | 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. 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. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | 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. 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. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | 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. 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. |
63691 | -1 | 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. 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. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | 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. 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. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | 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. 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. |
63660 | Revise/Remove Neuroelectrode | 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. 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. |
95973 | Analyze neurostim complex | 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. 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. |
E0751 | PULSE GENERATOR OR RECEIVER | 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. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | 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. |
63690 | -1 | 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. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | 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. |
E0753 | NEUROSTIMUL ELECTRODES/LEADS | 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. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | 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. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | 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. |
63691 | -1 | 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. |
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. |
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