code
stringlengths 4
12
| description
stringlengths 2
264
| codetype
stringclasses 8
values | context
stringlengths 160
15.5k
|
|---|---|---|---|
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
17999 | UNLISTED PROC SKIN SUBQ | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
1999 | ANESTHESIOLOGY GROUP | CPT | What are CPT codes
Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health professionals) use these codes to describe and report services and procedures to private and federal payers. Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. |
00100 | ANESTH SALIVARY GLAND | CPT | What are CPT codes
Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health professionals) use these codes to describe and report services and procedures to private and federal payers. Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. |
99199 | Unlisted special svc px/rprt | CPT | What are CPT codes
Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health professionals) use these codes to describe and report services and procedures to private and federal payers. Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. |
01999 | Unlisted anesth procedure | CPT | What are CPT codes
Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health professionals) use these codes to describe and report services and procedures to private and federal payers. Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. |
1999 | ANESTHESIOLOGY GROUP | CPT | Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. |
00100 | ANESTH SALIVARY GLAND | CPT | Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. |
99199 | Unlisted special svc px/rprt | CPT | Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. |
01999 | Unlisted anesth procedure | CPT | Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. |
1999 | ANESTHESIOLOGY GROUP | CPT | These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). |
00100 | ANESTH SALIVARY GLAND | CPT | These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). |
99199 | Unlisted special svc px/rprt | CPT | These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). |
01999 | Unlisted anesth procedure | CPT | These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). |
1999 | ANESTHESIOLOGY GROUP | CPT | There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). They range from 0016T-0207T and these codes may become Category I codes if the CPT Editorial Panel approves them. |
00100 | ANESTH SALIVARY GLAND | CPT | There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). They range from 0016T-0207T and these codes may become Category I codes if the CPT Editorial Panel approves them. |
99199 | Unlisted special svc px/rprt | CPT | There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). They range from 0016T-0207T and these codes may become Category I codes if the CPT Editorial Panel approves them. |
01999 | Unlisted anesth procedure | CPT | There are three categories of CPT codes:
- Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category)
- Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value
- Category III: Temporary codes assigned to tracking the efficacy of emerging and experimental technologies, procedures, and services
Category I CPT codes are divided into six main sections:
- Evaluation and Management: 99201 – 99499
- Anesthesia: 00100 – 01999; 99100 – 99140
- Surgery: 10021 – 69990
- Radiology: 70010 – 79999
- Pathology and Laboratory: 80047 – 89398
- Medicine/Medical Services and Procedures: 90281 – 99199; 99500 – 99607
Each of these sections further includes its own subfields. Category II of CPT codes is not associated with any relative value, so the services in this group are billed with a $0.00 billable charge amount. The Performance Measures Advisory Group (PMAG), which is an advisory body to the CPT Editorial Committee and the CPT/HCPAC Advisory Committee, reviews the codes in accordance with the medical and additional expertise. This category includes 10 sections:
- Composite Measures: 0001F – 0015F
- Patient Management: 0500F – 0584F
- Patient History: 1000F – 1505F
- Physical Examination: 2000F – 2060F
- Diagnostic/Screening Processes or Results: 3006F – 3776F
- Therapeutic, Preventive, or Other Interventions: 4000F – 4563F
- Follow-up or Other Outcomes: 5005F – 5250F
- Patient Safety: 6005F – 6150F
- Structural Measures: 7010F – 7025F
- Non-measure Listing: 9001F – 9007F
Since it covers emerging technologies only, Category III contains temporary CPT codes (which stay there for up to five years). They range from 0016T-0207T and these codes may become Category I codes if the CPT Editorial Panel approves them. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0360 | Each additional hr 1-8 hrs | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86821 | Lymphocyte culture mixed | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0361 | Prolong chemo infuse>8hrs pu | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86822 | Lymphocyte culture primed | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0359 | Chemotherapy IV one hr initi | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0362 | Each add sequential infusion | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0356 | HORMONAL 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0360 | Each additional hr 1-8 hrs | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86821 | Lymphocyte culture mixed | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0361 | Prolong chemo infuse>8hrs pu | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86822 | Lymphocyte culture primed | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0359 | Chemotherapy IV one hr initi | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0362 | Each add sequential infusion | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0356 | HORMONAL 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0360 | Each additional hr 1-8 hrs | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86821 | Lymphocyte culture mixed | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0361 | Prolong chemo infuse>8hrs pu | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0359 | Chemotherapy IV one hr initi | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0362 | Each add sequential infusion | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0356 | HORMONAL 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated: CPT-4 codes: 38230 added; HCPCS: G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure 41.01, 41.09 added, "(harvest) of stem cells" added to Covered Codes: CPT-4 codes: 38204 86812, 86813, 86816, 86817, 86821, 86822 added; ICD-9 Procedure 41.02. 41.03 added to Non-Covered Codes
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0267 | Bone marrow or psc harvest | CPT | 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0266 | Thawing + expansion froz cel | CPT | 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0265 | Cryopresevation Freeze+stora | CPT | 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
86825 | X-MATCHAHG | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
38207 | PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about FEP and State/and School Employee subscribers. Code Reference section was updated as follows: added instructions for coding in conjunction with 38207 - 38215; added ICD-9 procedure code 41.00 to covered code table; revised descriptions of ICD-9 procedure codes 41.04 & 41.07; added ICD-9 diagnosis code 158.9 to covered code table; removed deleted HCPCS Code G0363; added CPT Codes 86825 and 86826 to non-covered codes table and added HCPCS Codes S2140 & S2142 to non-covered codes table. 04/28/2010: Policy description updated. Policy statement added to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. |
E1340 | Repair for DME - per 15 min | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
A4556 | PT ELECTRODES | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0608 | APNEA MONITOR | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
A4557 | Lead wires, pair | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0619 | Apnea monitor w recorder | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0618 | Apnea monitor, without recording feature | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.