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86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
96530 | Syst pump refill & main | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0362 | Each add sequential infusion | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
Q0084 | HC CHEMOTHERAPY - IM PHYS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38242 | Transplt allo lymphocytes | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0267 | Bone marrow or psc harvest | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0265 | Cryopresevation Freeze+stora | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0266 | Thawing + expansion froz cel | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
86825 | X-MATCHAHG | HCPCS | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
86826 | Hla x-match noncytotoxc addl | HCPCS | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
G0267 | Bone marrow or psc harvest | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
G0265 | Cryopresevation Freeze+stora | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
G0266 | Thawing + expansion froz cel | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
86825 | X-MATCHAHG | HCPCS | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0267 | Bone marrow or psc harvest | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0265 | Cryopresevation Freeze+stora | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0266 | Thawing + expansion froz cel | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
86825 | X-MATCHAHG | HCPCS | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
38241 | Transplt autol hct/donor | HCPCS | Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
38240 | Transplt allo hct/donor | HCPCS | Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
96445 | Chemotherapy, intracavitary | HCPCS | Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
38241 | Transplt autol hct/donor | HCPCS | 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
38240 | Transplt allo hct/donor | HCPCS | 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
96445 | Chemotherapy, intracavitary | HCPCS | 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/26/2016: Policy number added. Blue Cross Blue Shield Association policy # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0267 | Bone marrow or psc harvest | CPT | 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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
S2140 | Cord blood harvesting for 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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0265 | Cryopresevation Freeze+stora | CPT | 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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0266 | Thawing + expansion froz cel | CPT | 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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
S2142 | Cord blood-derived stem-cell 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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
86826 | Hla x-match noncytotoxc addl | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
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