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G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: 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. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0360 | Each additional hr 1-8 hrs | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0362 | Each add sequential infusion | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0359 | Chemotherapy IV one hr initi | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | 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. 10/21/2010: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38241 | Transplt autol hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38240 | Transplt allo hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0265 | Cryopresevation Freeze+stora | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38242 | Transplt allo lymphocytes | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0266 | Thawing + expansion froz cel | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96445 | Chemotherapy, intracavitary | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0267 | Bone marrow or psc harvest | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0267 | Bone marrow or psc harvest | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0267 | Bone marrow or psc harvest | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
15878 | Suction lipectomy upr extrem | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
17999 | UNLISTED PROC SKIN SUBQ | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
92508 | Speech/hearing therapy | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92551 | Test for screening hearing | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92588 | PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92524 | ST SPEECH BEHAVIORAL QUALI OF | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92522 | ST SPEECH EVAL OF SOUND PRODUC | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92620 | PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92621 | PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92523 | ST SPEECH EVAL SOUND W LANGUAG COMPREHEN | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
S9128 | Speech therapy, in the home, | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92507 | Treatment of speech, language, voice, communication, and/or hearing processing disorder | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92521 | ST SPEECH EVAL OF FLUENCY | HCPCS | The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92508 | Speech/hearing therapy | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92551 | Test for screening hearing | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92588 | PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92524 | ST SPEECH BEHAVIORAL QUALI OF | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92522 | ST SPEECH EVAL OF SOUND PRODUC | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92620 | PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92621 | PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92523 | ST SPEECH EVAL SOUND W LANGUAG COMPREHEN | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
S9128 | Speech therapy, in the home, | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92507 | Treatment of speech, language, voice, communication, and/or hearing processing disorder | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92521 | ST SPEECH EVAL OF FLUENCY | HCPCS | The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||group, two or more individuals|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92551 - 92588||Audiological function tests with medical diagnostic evaluation|
|92620||Evaluation of central auditory function, with report; initial 60 minutes|
|92621||each additional 15 minutes|
|Other HCPCS codes related to the CPB:|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes not covered for indications listed in the CPB:|
|H93.25||Central auditory processing disorder|
|H93.291 - H93.299||Other abnormal auditory perceptions| |
92065 | PR ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP | HCPCS | Nevertheless, the results showed that vergence treatment might help dyslexics. They stated that larger studies are needed to provide guidance in this area. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F48.9||Nonpsychotic mental disorder, unspecified|
|F63.81 - F63.89||Other impulse disorders|
|F70 - F79||Intellectual disabilities|
|F80.0 - F81.9||Specific developmental disorders of speech, language and scholastic skills|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|H54.7||Unspecified visual loss|
|R27.0 - R27.9||Other lack of coordination|
|R41.840 - R41.89||Other specific cognitive deficit|
|R48.0||Dyslexia and alexia|
|R48.1 - R48.8||Other symbolic dysfunction| |
92065 | PR ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP | HCPCS | They stated that larger studies are needed to provide guidance in this area. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F48.9||Nonpsychotic mental disorder, unspecified|
|F63.81 - F63.89||Other impulse disorders|
|F70 - F79||Intellectual disabilities|
|F80.0 - F81.9||Specific developmental disorders of speech, language and scholastic skills|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|H54.7||Unspecified visual loss|
|R27.0 - R27.9||Other lack of coordination|
|R41.840 - R41.89||Other specific cognitive deficit|
|R48.0||Dyslexia and alexia|
|R48.1 - R48.8||Other symbolic dysfunction| |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
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. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
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