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G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38213 | PR TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38211 | Tumor cell deplete of harvst | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38207 | PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38208 | Thaw preserved stem cells | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38210 | T-cell depletion of harvest | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38212 | Rbc depletion of harvest | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. |
G0267 | Bone marrow or psc harvest | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0266 | Thawing + expansion froz cel | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0265 | Cryopresevation Freeze+stora | CPT | ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. |
G0267 | Bone marrow or psc harvest | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
G0266 | Thawing + expansion froz cel | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
G0265 | Cryopresevation Freeze+stora | CPT | ICD-9 2007 revisions added to policy
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias. |
81003 | URINE SPECIFIC GRAVITY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81005 | URINALYSIS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81001 | URINALYSIS AUTO W/SCOPE | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81099 | URINE COLLECTION | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81015 | URINE MICROSCOPIC (ONLY) | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81000 | HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81002 | URN DIPST/TAB RGNT NONAUTO W/O | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81020 | Urinalysis glass test | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81007 | Urine screen for bacteria | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. |
81003 | URINE SPECIFIC GRAVITY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81005 | URINALYSIS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81001 | URINALYSIS AUTO W/SCOPE | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81099 | URINE COLLECTION | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81015 | URINE MICROSCOPIC (ONLY) | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81000 | HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88368 | PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88367 | PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88271 | MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH) | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88299 | Unlisted cytogenetic study | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81002 | URN DIPST/TAB RGNT NONAUTO W/O | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81020 | Urinalysis glass test | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
81007 | Urine screen for bacteria | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC)
6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 added
11/2001: Reviewed by MPAC; Bladder Tumor Antigen or NMP-22 (Nuclear Matrix Protein 22) medically necessary
4/18/2002: Type of Service and Place of Service deleted
8/29/2003: Policy title "Bladder Tumor Antigen" renamed "Urinary Tumor Markers for Bladder Cancer, "Description" section updated to be consistent with BCBSA, NMP-22 added to the "Policy" and "Policy History" sections, Sources and Code Reference sections updated, ICD-9 diagnosis code range 188.0-188.9, 198.1 listed separately, CPT code range 81000-81020, 81099 listed separately, hyperlink moved to the "Description" section
4/7/2004: Code Reference section updated, CPT code 86316 deleted from covered code table, non-covered table and CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81020, 81099 deleted
3/15/2006: Coding updated. HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. |
88368 | PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88367 | PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88299 | Unlisted cytogenetic study | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
88271 | MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH) | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
86316 | IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH | HCPCS | HCPCS 2006 revisions added to policy
12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7
4/29/2008: Policy reviewed, no changes
9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied
7/24/2009: Policy Description section updated for clarification of the commercially available tumor biomarkers, Policy Statement section updated for clarification of the commercially available tumor biomarkers; and modified for FDA- approved uses, Policy Guidelines section updated, CPT Codes 86316, 88271, 88299, 88367, 88368 added to covered table, ICD-9 Diagnosis code V10.51 added to covered table, note added to CPT code 88299. 06/07/2010: Policy description updated regarding available tests. Policy statement unchanged. |
A4650 | Implant radiation dosimeter | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61797 | Srs cran les simple addl | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0251 | Linear acc based stero radio | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77372 | Srs linear based | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77432 | Stereotactic radiation trmt | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0339 | Robot lin-radsurg com, first | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
63621 | Srs spinal lesion addl | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77373 | Sbrt delivery | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0340 | Robt lin-radsurg fractx 2-5 | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0173 | STEREO RADOISURGERY,COMPLETE | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
63620 | Srs spinal lesion | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
A4648 | WIRE LOCAL SPECBOARD | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61798 | Srs cranial lesion complex | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61800 | PR APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61799 | Srs cran les complex addl | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61796 | Srs cranial lesion simple | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
32701 | Thorax stereo rad targetw/tx | HCPCS | For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
A4650 | Implant radiation dosimeter | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61797 | Srs cran les simple addl | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0251 | Linear acc based stero radio | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77372 | Srs linear based | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77432 | Stereotactic radiation trmt | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0339 | Robot lin-radsurg com, first | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
63621 | Srs spinal lesion addl | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77373 | Sbrt delivery | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0340 | Robt lin-radsurg fractx 2-5 | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
G0173 | STEREO RADOISURGERY,COMPLETE | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
63620 | Srs spinal lesion | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
A4648 | WIRE LOCAL SPECBOARD | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61798 | Srs cranial lesion complex | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61800 | PR APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61799 | Srs cran les complex addl | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
61796 | Srs cranial lesion simple | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
32701 | Thorax stereo rad targetw/tx | HCPCS | Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including:
All other clinical sites or indications are considered experimental and investigational but will be considered on a case by case basis. |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:|
|20660||Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)|
|32701||Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment|
|61796||Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion|
|+ 61797||each additional cranial lesion, simple (List separately in addition to code for primary procedure)|
|61798||1 complex cranial lesion|
|+ 61799||each additional cranial lesion, complex (List separately in addition to code for primary procedure)|
|61800||Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)|
|63620||Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion|
|63621||each additional spinal lesion (List separately in addition to code for primary procedure)|
|77371||Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based|
|77372||linear accelerator based|
|77373||Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|77432||Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)|
|77435||Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions|
|HCPCS codes covered if selection criteria are met:|
|G0173||Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session|
|G0251||Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment|
|G0339||Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment|
|G0340||Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment|
|Other HCPCS codes related to the CPB:|
|A4648||Tissue marker, implantable, any type, each|
|A4650||Implantable radiation dosimeter, each|
|ICD-10 codes covered if selection criteria are met:|
|C00 - C96||Neoplasms|
|I67.1||Cerebral aneurysm, nonruptured|
|Q28.2 - Q28.3||Other congenital malformations of circulatory system|
|ICD-10 codes not covered for indications listed in the CPB:|
|G21.0 - G21.9||Secondary parkinsonism|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.001 - G44.099||Cluster headache and trigeminal autonomic cephalgias (TAC)|
|R56.1||Post traumatic seizures|
|R56.9||Unspecified convulsions [seizures nos]|
|R92.0||Mammographic microcalcification found on diagnostic imaging of breast| |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | Scintimammography, breast-specific gamma imaging (BSGI), and molecular breast imaging (MBI) are considered investigational in all applications, including but not limited to their use as an adjunct to mammography or in staging the axillary lymph nodes. Preoperative or intraoperative sentinel lymph node detection using handheld or mounted mobile gamma cameras is considered investigational. The most commonly used radiopharmaceutical used in for BSGI or MBI is technetium Tc 99m sestamibi (marketed by Draxis Specialty Pharmaceuticals Inc., Cardinal Health 414, LLC, Mallinckrodt Inc., and Pharmalucence, Inc.). There is a specific HCPCS code for this radiopharmaceutical:
A9500: Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries. BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity. |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | Preoperative or intraoperative sentinel lymph node detection using handheld or mounted mobile gamma cameras is considered investigational. The most commonly used radiopharmaceutical used in for BSGI or MBI is technetium Tc 99m sestamibi (marketed by Draxis Specialty Pharmaceuticals Inc., Cardinal Health 414, LLC, Mallinckrodt Inc., and Pharmalucence, Inc.). There is a specific HCPCS code for this radiopharmaceutical:
A9500: Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries. BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity. This policy was created in January 1998 and updated periodically with literature review. |
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