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J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
38242 | Transplt allo lymphocytes | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
86822 | Lymphocyte culture primed | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/19/2005: Code Reference section updated, codes G0355-G0364 added, 38204, 38205, 38240, 38242, 86812-86822, J9000-J9999 deleted; ICD9 procedure code 41.01, 41.09 added, 41.05, 41.08, 41.91 deleted; description of ICD9 procedure code 99.79 revised; HCPCS statement added on how to report J9000-J9999 codes. 03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/30/2008: Description updated, "high-dose chemotherapy" removed from policy title and statement. "Stem-cell support" wording replaced with "stem-cell transplantation". |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. |
96445 | Chemotherapy, intracavitary | HCPCS | Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated in policy guidelines section. |
96445 | Chemotherapy, intracavitary | HCPCS | Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated in policy guidelines section. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated in policy guidelines section. |
81003 | URINE SPECIFIC GRAVITY | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81005 | URINALYSIS | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81001 | URINALYSIS AUTO W/SCOPE | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81099 | URINE COLLECTION | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81015 | URINE MICROSCOPIC (ONLY) | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81000 | HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81002 | URN DIPST/TAB RGNT NONAUTO W/O | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81020 | Urinalysis glass test | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81007 | Urine screen for bacteria | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81003 | URINE SPECIFIC GRAVITY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81005 | URINALYSIS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81001 | URINALYSIS AUTO W/SCOPE | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81099 | URINE COLLECTION | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81015 | URINE MICROSCOPIC (ONLY) | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81000 | HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88368 | PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88367 | PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88271 | MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH) | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88299 | Unlisted cytogenetic study | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81002 | URN DIPST/TAB RGNT NONAUTO W/O | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81020 | Urinalysis glass test | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81007 | Urine screen for bacteria | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88368 | PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88367 | PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88299 | Unlisted cytogenetic study | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88271 | MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH) | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/20/2005: Code Reference section updated, codes 38230, G0355-G0364 added, J9000-J9999 deleted; ICD9 procedure codes 41.02, 41.03, 41.04, 41.09 added
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. |
86825 | X-MATCHAHG | HCPCS | CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. |
86826 | Hla x-match noncytotoxc addl | HCPCS | CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. |
86826 | Hla x-match noncytotoxc addl | HCPCS | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
G0267 | Bone marrow or psc harvest | CPT | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
G0265 | Cryopresevation Freeze+stora | CPT | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
G0266 | Thawing + expansion froz cel | CPT | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
86825 | X-MATCHAHG | HCPCS | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | "High-dose chemotherpay" term removed from title
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity conditioning for HSCT; however, the policy statement was unchanged. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. |
86826 | Hla x-match noncytotoxc addl | HCPCS | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes. |
38241 | Transplt autol hct/donor | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
38240 | Transplt allo hct/donor | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
38242 | Transplt allo lymphocytes | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
96445 | Chemotherapy, intracavitary | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. |
38241 | Transplt autol hct/donor | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
38240 | Transplt allo hct/donor | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
38242 | Transplt allo lymphocytes | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
96445 | Chemotherapy, intracavitary | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." |
38241 | Transplt autol hct/donor | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
38240 | Transplt allo hct/donor | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
38242 | Transplt allo lymphocytes | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
96445 | Chemotherapy, intracavitary | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. |
38241 | Transplt autol hct/donor | HCPCS | 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to make minor changes: 1) "allogeneic stem cell" changed to "allogeneic hematopoietic stem cell" and 2) "Pancreas cancer" changed to "Pancreatic cancer." Investigative definitions updated in policy guidelines. 05/25/2016: Policy number added. |
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