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E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
E0936 | CPM device, other than knee | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D2970 | Temp crown (fractured tooth) | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D0290 | Skull/facial bone image | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
A4595 | TENS suppl 2 lead per month | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. |
D7995 | Synthetic graft facial bones | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
A4630 | Repl bat t.e.n.s. own by pt | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D2940 | PR PROTECTIVE RESTORATION | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D2915 | Recement cast or prefab post | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
E0936 | CPM device, other than knee | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D2970 | Temp crown (fractured tooth) | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D0290 | Skull/facial bone image | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
A4595 | TENS suppl 2 lead per month | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. |
D7995 | Synthetic graft facial bones | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
A4630 | Repl bat t.e.n.s. own by pt | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D2940 | PR PROTECTIVE RESTORATION | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D2915 | Recement cast or prefab post | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
E0936 | CPM device, other than knee | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D2970 | Temp crown (fractured tooth) | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
D0290 | Skull/facial bone image | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
A4595 | TENS suppl 2 lead per month | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. |
64570 | Remove vagus n eltrd | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. 03/07/2011: Added new CPT codes 64568, 64569, and 64570 to the Code Reference section. 09/23/2011: Clarified policy statement regarding ultrasound. |
64568 | PR OPEN IMPLANTATION CRANIAL NERVE NEA & PULSE GEN | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. 03/07/2011: Added new CPT codes 64568, 64569, and 64570 to the Code Reference section. 09/23/2011: Clarified policy statement regarding ultrasound. |
64569 | Revise/repl vagus n eltrd | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Codes table. 03/07/2011: Added new CPT codes 64568, 64569, and 64570 to the Code Reference section. 09/23/2011: Clarified policy statement regarding ultrasound. |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | Medical Necessity documentation and a treatment plan, including charges for each service, must be submitted to and approved prior to the commencement of treatment. No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider. Added CPT codes D0368, D0384, and S8262 to the Covered Codes table. Removed deleted CPT code D0360 from the Code Reference section. 09/19/2014: Policy reviewed; description updated. |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider. Added CPT codes D0368, D0384, and S8262 to the Covered Codes table. Removed deleted CPT code D0360 from the Code Reference section. 09/19/2014: Policy reviewed; description updated. Policy statement unchanged. |
E0485 | Oral device/appliance prefab | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. |
E0486 | Oral device/appliance cusfab | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. |
20606 | PROFEE ARTHROCENTESIS OR INJ JNT OR BURS | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. |
E0485 | Oral device/appliance prefab | HCPCS | 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. |
E0486 | Oral device/appliance cusfab | HCPCS | 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. |
E0485 | Oral device/appliance prefab | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
E0486 | Oral device/appliance cusfab | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
D5875 | Prosthesis modification | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
D5630 | Rep partial denture clasp | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. |
E0485 | Oral device/appliance prefab | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
E0486 | Oral device/appliance cusfab | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
D5875 | Prosthesis modification | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
D5630 | Rep partial denture clasp | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. |
E0485 | Oral device/appliance prefab | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
E0486 | Oral device/appliance cusfab | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
D5875 | Prosthesis modification | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
D5630 | Rep partial denture clasp | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
0340 | Nuclear Medicine - General Classification | RC | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
D5875 | Prosthesis modification | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
D5630 | Rep partial denture clasp | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
0230 | Incremental Nursing Charge - General Classification | RC | SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
64550, 64553, 64555, 64560, 64561, 64565, 64568, 64569, 64570, 64573, 64575, 64577, 64580, 64581, 64585, 64590, 64595
Unlisted ultrasound procedure
Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy code range
Biofeedback training by any modality
Needle electromyography; cranial nerve supplied muscle(s), unilateral
Needle electromyography; cranial nerve supplied muscles, bilateral
Short-Latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method
Unlisted neurological or neuromuscular diagnostic procedure
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics;
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; with dynamic plantar pressure measurements during walking
Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
Physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
Application of a modality to one or more areas; hot or cold packs
Applicaton of a modality to one or more areas; traction, mechanical
Application of a modality to one or more areas; electrical stimulation (unattended)
Application of a modality to one or more areas; diathermy (eg, microwave)
Application of a modality to one or more areas; infrared
Application of a modality to one or more areas, electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; iontophoresis, each 15 minutes
Application of a modality to one or more areas; ultrasound, each 15 minutes
Unlisted modality (specify type and time if constant attendance)
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
Unlisted physical medicine/rehabilitation service or procedure
Electrical stimulator supplies, 2 lead, per month (e.g. TENS, NMES)
Replacement batteries. Medically necessary transcutaneous electrical stimulator, owned by patient
D0210, D0220, D0230
Intraoral x-rays code range
D1510, D1515, D1520, D1525, D1550
Space maintainers code range
Removal of fixed space maintainer
D2140, D2150, D2160, D2161, D2330, D2331, D2332
Amalgam restorations code range
D2335, D2390, D2391, D2392, D2393, D2394
Resin-based composite restorations code range
D2410, D2420, D2430
Gold foil restorations code range
D2510, D2520, D2530
Inlay - metallic restorations code range
D2542, D2543, D2544
Onlay – metallic restorations code range
D2610, D2620, D2630
Inlay - porcelain/ceramic restorations code range
D2642, D2643, D2644
Onlay - porcelain/ceramic restorations code range
D2650, D2651, D2652
Inlay - resin-based composite composite/resin restorations code range
D2662, D2663, D2664
Onlay - resin-based composite composite/resin restorations code range
D2710, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2799
Crowns code range
Recement cast or prefabricated post and core
D2930, D2931, D2932, D2933, D2934
Prefabricated stainless steel crowns code range
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Post and core in addition to crown, indirectly fabricated
Each additional indirectly fabricated post - same tooth
Prefabricated post and core in addition to crown
Post removal (not in conjunction with endodontic therapy)
Each additional prefabricated post - same tooth
D2960, D2961, D2962
Labial veneer restorations code range
Temporary crown (fractured tooth) (D2970 deleted 12/31/2015)
Crown repair, by report
Unspecified restorative procedure, by report
Anatomical crown exposure - four or more contiguous teeth per quadrant
Anatomical crown exposure - one to three teeth per quadrant
D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5225, D5226, D5281
Complete and partial dentures code range
D5410, D5411, D5421, D5422
Adjustments to removal prostheses code range
Repair broken complete denture base
Replace missing or broken teeth - complete denture (each tooth)
D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671
Repair to partial dentures (D5630 and D5660 revised 01/01/2016)
D5710, D5711, D5720, D5721
Denture rebase procedures code range
D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
Denture reline procedures
D5810, D5811, D5820, D5821
Interim prothesis code range
D5850, D5851, D5860, D5861, D5862, D5867, D5875, D5899
Other removable prosthetic services (D5875 revised 01/01/2016)
Recement implant/abutment supported crown
Recement implant/abutment supported fixed partial denture
Arthroscopy, diagnostic with or without biopsy
D8010, D8020, D8030, D8040, D8050, D8060, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8690, D8691, D8692, D8693, D8999
Other orthodontic treatment code range
Heat lamp, without stand (table model), includes bulb, or infrared element
Heat lamp, with stand, includes bulb, or infrared element
Infrared heating pad system
TENS device, two lead, localized stimulation
TENS device; four or more leads, for multiple nerve stimulation
Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
Electromyography (emg), biofeedback device
Continuous passive motion exercise device, not otherwise specified
Hyaluronan or derivative code range
Surface electromyography (emg)
Other diagnostic procedures on facial bones and joints (Arthroscopy)
Inspection of Right Temporomandibular Joint, Open Approach
Inspection of Right Temporomandibular Joint, Percutaneous Approach
Inspection of Right Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Right Temporomandibular Joint, External Approach
Inspection of Left Temporomandibular Joint, Open Approach
Inspection of Left Temporomandibular Joint, Percutaneous Approach
Inspection of Left Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Left Temporomandibular Joint, External Approach |
0210 | Other Inpatient | RC | SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
64550, 64553, 64555, 64560, 64561, 64565, 64568, 64569, 64570, 64573, 64575, 64577, 64580, 64581, 64585, 64590, 64595
Unlisted ultrasound procedure
Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy code range
Biofeedback training by any modality
Needle electromyography; cranial nerve supplied muscle(s), unilateral
Needle electromyography; cranial nerve supplied muscles, bilateral
Short-Latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method
Unlisted neurological or neuromuscular diagnostic procedure
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics;
Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; with dynamic plantar pressure measurements during walking
Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles
Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
Physician review and interpretation of comprehensive computer based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
Application of a modality to one or more areas; hot or cold packs
Applicaton of a modality to one or more areas; traction, mechanical
Application of a modality to one or more areas; electrical stimulation (unattended)
Application of a modality to one or more areas; diathermy (eg, microwave)
Application of a modality to one or more areas; infrared
Application of a modality to one or more areas, electrical stimulation (manual), each 15 minutes
Application of a modality to one or more areas; iontophoresis, each 15 minutes
Application of a modality to one or more areas; ultrasound, each 15 minutes
Unlisted modality (specify type and time if constant attendance)
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
Unlisted physical medicine/rehabilitation service or procedure
Electrical stimulator supplies, 2 lead, per month (e.g. TENS, NMES)
Replacement batteries. Medically necessary transcutaneous electrical stimulator, owned by patient
D0210, D0220, D0230
Intraoral x-rays code range
D1510, D1515, D1520, D1525, D1550
Space maintainers code range
Removal of fixed space maintainer
D2140, D2150, D2160, D2161, D2330, D2331, D2332
Amalgam restorations code range
D2335, D2390, D2391, D2392, D2393, D2394
Resin-based composite restorations code range
D2410, D2420, D2430
Gold foil restorations code range
D2510, D2520, D2530
Inlay - metallic restorations code range
D2542, D2543, D2544
Onlay – metallic restorations code range
D2610, D2620, D2630
Inlay - porcelain/ceramic restorations code range
D2642, D2643, D2644
Onlay - porcelain/ceramic restorations code range
D2650, D2651, D2652
Inlay - resin-based composite composite/resin restorations code range
D2662, D2663, D2664
Onlay - resin-based composite composite/resin restorations code range
D2710, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2799
Crowns code range
Recement cast or prefabricated post and core
D2930, D2931, D2932, D2933, D2934
Prefabricated stainless steel crowns code range
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Post and core in addition to crown, indirectly fabricated
Each additional indirectly fabricated post - same tooth
Prefabricated post and core in addition to crown
Post removal (not in conjunction with endodontic therapy)
Each additional prefabricated post - same tooth
D2960, D2961, D2962
Labial veneer restorations code range
Temporary crown (fractured tooth) (D2970 deleted 12/31/2015)
Crown repair, by report
Unspecified restorative procedure, by report
Anatomical crown exposure - four or more contiguous teeth per quadrant
Anatomical crown exposure - one to three teeth per quadrant
D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5225, D5226, D5281
Complete and partial dentures code range
D5410, D5411, D5421, D5422
Adjustments to removal prostheses code range
Repair broken complete denture base
Replace missing or broken teeth - complete denture (each tooth)
D5610, D5620, D5630, D5640, D5650, D5660, D5670, D5671
Repair to partial dentures (D5630 and D5660 revised 01/01/2016)
D5710, D5711, D5720, D5721
Denture rebase procedures code range
D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761
Denture reline procedures
D5810, D5811, D5820, D5821
Interim prothesis code range
D5850, D5851, D5860, D5861, D5862, D5867, D5875, D5899
Other removable prosthetic services (D5875 revised 01/01/2016)
Recement implant/abutment supported crown
Recement implant/abutment supported fixed partial denture
Arthroscopy, diagnostic with or without biopsy
D8010, D8020, D8030, D8040, D8050, D8060, D8070, D8080, D8090, D8210, D8220, D8660, D8670, D8680, D8690, D8691, D8692, D8693, D8999
Other orthodontic treatment code range
Heat lamp, without stand (table model), includes bulb, or infrared element
Heat lamp, with stand, includes bulb, or infrared element
Infrared heating pad system
TENS device, two lead, localized stimulation
TENS device; four or more leads, for multiple nerve stimulation
Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
Electromyography (emg), biofeedback device
Continuous passive motion exercise device, not otherwise specified
Hyaluronan or derivative code range
Surface electromyography (emg)
Other diagnostic procedures on facial bones and joints (Arthroscopy)
Inspection of Right Temporomandibular Joint, Open Approach
Inspection of Right Temporomandibular Joint, Percutaneous Approach
Inspection of Right Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Right Temporomandibular Joint, External Approach
Inspection of Left Temporomandibular Joint, Open Approach
Inspection of Left Temporomandibular Joint, Percutaneous Approach
Inspection of Left Temporomandibular Joint, Percutaneous Endoscopic Approach
Inspection of Left Temporomandibular Joint, External Approach |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0362 | Each add sequential infusion | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86826 | Hla x-match noncytotoxc addl | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86825 | X-MATCHAHG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
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