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30462 | Revision of nose | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21110 | PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
0232T | Njx platelet plasma | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21210 | PR GRAFT BONE NASAL/MAXILLARY/MALAR AREAS | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20696 | PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT 1ST&SUBSQ | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
30400 | Reconstruction of nose | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21120 | Reconstruction of chin | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20692 | PR APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
38220 | PR DIAGNOSTIC BONE MARROW ASPIRATIONS | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D7949 | Reconstruct midface w/graft | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
42225 | Reconstruct cleft palate | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20697 | PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT EXCHANGE | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D6010 | PR SURG PLCMT IMPL BODY: ENDOSTEAL | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
S9055 | Procuren or other growth fac | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D7946 | Reconstruction maxilla total | HCPCS | The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20694 | Rmvl ext fixj sys under anes | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21206 | Reconstruct upper jaw bone | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
42200 | Reconstruct cleft palate | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D6199 | PR UNSPEC IMPLANT PROCEDURE BY REPORT | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21196 | Reconst lwr jaw w/fixation | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21247 | Reconstruct lower jaw bone | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D8999 | PR UNS ORTHODONTIC PROCEDURE BY REPORT | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20693 | PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D8010 | PR LTD ORTHODONT TX PRIMARY DENTITION | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
30462 | Revision of nose | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21110 | PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
0232T | Njx platelet plasma | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21210 | PR GRAFT BONE NASAL/MAXILLARY/MALAR AREAS | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20696 | PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT 1ST&SUBSQ | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
30400 | Reconstruction of nose | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
21120 | Reconstruction of chin | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20692 | PR APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
38220 | PR DIAGNOSTIC BONE MARROW ASPIRATIONS | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D7949 | Reconstruct midface w/graft | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
42225 | Reconstruct cleft palate | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
20697 | PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT EXCHANGE | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D6010 | PR SURG PLCMT IMPL BODY: ENDOSTEAL | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
S9055 | Procuren or other growth fac | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
D7946 | Reconstruction maxilla total | HCPCS | The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|20692||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)|
|20693||Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))|
|20694||Removal, under anesthesia, of external fixation system|
|20696||Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)|
|20697||exchange (ie, removal and replacement) of strut, each|
|CPT codes not covered for indications listed in the CPB:|
|0232T||Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed|
|Other CPT codes related to the CPB:|
|21110||Application of interdental fixation device for conditions other than fracture or dislocation, includes removal|
|21120 - 21196||Repair, revision, and/or reconstruction bones of face|
|21206||Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21247||Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)|
|30400 - 30462||Rhinoplasty|
|38220||Bone marrow, aspiration only|
|42200 - 42225||Palatoplasty|
|HCPCS codes not covered for indicationslisted in the CPB:|
|S9055||Procuren or other growth factor preparation to promote wound healing|
|Other HCPCS codes related to the CPB:|
|D6010 - D6199||Implant services|
|D7946 - D7949||LeFort procedures I, II, or III|
|D8010 - D8999||Orthodontic dental procedures|
|ICD-10 codes covered if selection criteria are met:|
|M26.00 - M26.59||Dentofacial anomalies [including malocclusion]|
|Q35.1 - Q35.9||Cleft palate|
|Q37.0 - Q37.9||Cleft palate with cleft lip|
|Q67.0 - Q67.4||Congenital deformities of skull, face and jaw|
|Q75.0 - Q75.9||Congenital malformation of skull and face bones [includes hemifacial microstomia]|
|Q87.0||Congenital malformation syndromes predominantly affecting facial appearance|
|ICD-10 codes not covered for indications listed in the CPB:|
|G47.33||Obstructive sleep apnea (adult) (pediatric)|
|M95.2||Other acquired deformity of head [acquired craniofacial defects]|
|Z41.1||Encounter for cosmetic surgery|
|Z46.3||Encounter for fitting and adjustment of dental prosthetic device|
|Z46.4||Encounter for fitting and adjustment of orthodontic device| |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS Level III contains alphanumeric codes that are assigned
by Medicaid state agencies to identify additional items
and services not included in levels I or II. These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. HIPAA does not replace the states' roles as primary regulators
of insurance. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | 04/12/2010: Description section revised to add the four oncologic applications of PET Scanning; Policy section revised to add indications considered medically necessary for Melanoma, Lymphoma, lung; colorectal; pancreatic; head & neck; esophageal; breast; ovarian and testicular cancers. Added indications considered medically necessary for differentiated thyroid and cervical cancers; added prostate cancer and cancer surveillance as investigational for all indications. Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Added indications considered medically necessary for differentiated thyroid and cervical cancers; added prostate cancer and cancer surveillance as investigational for all indications. Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table: 140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81. Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. Corrected typo to change 235.4 to 236.4. |
A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | HCPCS | Moved HCPCS Code A9580 from non-covered to covered table. 10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2, 235.3, 235.4, 784.2, and 795.81. Corrected typo to change 235.4 to 236.4. Added 199.1, 209.20, 209.72, and 233.6 to the Covered Codes table. |
97533 | Therapy procedure using sensory experiences | HCPCS | Studies of sensory-based interventions suggested that they may not be effective; however, they did not follow recommended protocols or target sensory processing problems. The authors concluded that although small RCTs resulted in positive effects for SIT, additional rigorous trials using manualized protocols for SIT are needed to evaluate effects for children with ASDs and sensory processing problems. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F43.20 - F43.29||Adjustment disorders|
|F80.9||Developmental disorder of speech and language, unspecified [communication disorder]|
|F81.0 - F81.9||Specific developmental disorders of scholastic skills|
|F84.0 - F84.9||Pervasive developmental disorders|
|F90.0 - F90.9||Attention-deficit hyperactivity disorders|
|F91.0 - F91.9||Conduct diorders|
|F93.0 - F93.9||Emotional disorders with onset specific to childhood|
|Q99.2||Fragile X chromosome|
|R62.50||Unspecified lack of expected normal physiological development in childhood|
|Z03.89||Encounter for observation for other suspected diseases and conditions ruled out [Observation for suspected mental condition]| |
97533 | Therapy procedure using sensory experiences | HCPCS | The authors concluded that although small RCTs resulted in positive effects for SIT, additional rigorous trials using manualized protocols for SIT are needed to evaluate effects for children with ASDs and sensory processing problems. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F43.20 - F43.29||Adjustment disorders|
|F80.9||Developmental disorder of speech and language, unspecified [communication disorder]|
|F81.0 - F81.9||Specific developmental disorders of scholastic skills|
|F84.0 - F84.9||Pervasive developmental disorders|
|F90.0 - F90.9||Attention-deficit hyperactivity disorders|
|F91.0 - F91.9||Conduct diorders|
|F93.0 - F93.9||Emotional disorders with onset specific to childhood|
|Q99.2||Fragile X chromosome|
|R62.50||Unspecified lack of expected normal physiological development in childhood|
|Z03.89||Encounter for observation for other suspected diseases and conditions ruled out [Observation for suspected mental condition]| |
G0202 | Scr mammo bi incl cad | HCPCS | Digital screening mammogram with CAD was performed. Findings: Negative. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. |
77052 | Comp screen mammogram add-on | HCPCS | Digital screening mammogram with CAD was performed. Findings: Negative. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. |
G0202 | Scr mammo bi incl cad | HCPCS | CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. Comparison: Mammogram one year prior. Findings: Bilateral digital implant screening mammogram, standard and displaced views were obtained. |
77052 | Comp screen mammogram add-on | HCPCS | CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. Comparison: Mammogram one year prior. Findings: Bilateral digital implant screening mammogram, standard and displaced views were obtained. |
G0202 | Scr mammo bi incl cad | HCPCS | Bilateral subglandular breast implants are noted. Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. |
77052 | Comp screen mammogram add-on | HCPCS | Bilateral subglandular breast implants are noted. Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. |
G0202 | Scr mammo bi incl cad | HCPCS | Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. |
77052 | Comp screen mammogram add-on | HCPCS | Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. |
L8692 | Non-osseointegrated snd proc | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medially necessary. The coverage guidelines outlined in the Medical Policy should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. |
L8692 | Non-osseointegrated snd proc | HCPCS | The coverage guidelines outlined in the Medical Policy should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. |
L8692 | Non-osseointegrated snd proc | HCPCS | POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. |
L8692 | Non-osseointegrated snd proc | HCPCS | ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement. |
L8692 | Non-osseointegrated snd proc | HCPCS | New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement. The intent of the policy statements unchanged. |
L8693 | IMPL COCLR 4MM BAHA TI ABTMNT B1300 | HCPCS | The intent of the policy statements unchanged. FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. |
L8693 | IMPL COCLR 4MM BAHA TI ABTMNT B1300 | HCPCS | FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged. |
L8693 | IMPL COCLR 4MM BAHA TI ABTMNT B1300 | HCPCS | 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged. 04/04/2013: Policy reviewed; no changes. |
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. 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. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
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. 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. |
96520 | Port pump refill & main | 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. 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. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m | 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. 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. |
86821 | Lymphocyte culture mixed | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
Q0083 | Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit | 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. 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. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | 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. 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. |
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. 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. |
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. 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. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
86822 | Lymphocyte culture primed | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
38240 | Transplt allo hct/donor | 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. 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. |
96545 | Cancer chemotherapy | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
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. 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. |
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. 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. |
Q0085 | Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit | 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. 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. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
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. 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. |
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. 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. |
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. 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. |
96530 | Syst pump refill & main | 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. 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. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | 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. 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. |
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. 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. |
Q0084 | HC CHEMOTHERAPY - IM PHYS | 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. 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. |
38242 | Transplt allo lymphocytes | 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. 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. |
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. 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. |
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. 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. |
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. 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. |
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. 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. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
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. 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. |
96520 | Port pump refill & main | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
86821 | Lymphocyte culture mixed | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
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