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train · 15.7k rows

code stringlengths 4 12	description stringlengths 2 264	codetype stringclasses 8 values	context stringlengths 160 15.5k
L8617	Transmitting coil for use with cochlear implant device, replacement	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
92601	PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
V5299	Hearing service	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
V5362	Speech screening	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
92604	Reprogram cochlear implt 7/>	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
1999	ANESTHESIOLOGY GROUP	CPT	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
92603	PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
L8619	PROCESSOR SOUND SONNET/RONDO 3 KT	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
92602	Reprogram cochlear implt <7	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
69949	Unlisted px inner ear	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
L8616	Microphone for use with cochlear implant device, replacement	HCPCS	In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated.
V5363	Language screening	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5336	Repair communication device	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92507	Treatment of speech, language, voice, communication, and/or hearing processing disorder	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5273	Ald for cochlear implant	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92508	Speech/hearing therapy	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5269	Alerting device, any type	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92510	Rehab for ear implant	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
L8615	Headset/headpiece for use with cochlear implant device, replacement	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
L8617	Transmitting coil for use with cochlear implant device, replacement	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92601	PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5299	Hearing service	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5362	Speech screening	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92604	Reprogram cochlear implt 7/>	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
1999	ANESTHESIOLOGY GROUP	CPT	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92603	PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
L8619	PROCESSOR SOUND SONNET/RONDO 3 KT	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
92602	Reprogram cochlear implt <7	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
69949	Unlisted px inner ear	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
L8616	Microphone for use with cochlear implant device, replacement	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 HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement.
V5363	Language screening	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
V5336	Repair communication device	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92507	Treatment of speech, language, voice, communication, and/or hearing processing disorder	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
V5273	Ald for cochlear implant	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92508	Speech/hearing therapy	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
V5269	Alerting device, any type	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92510	Rehab for ear implant	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8615	Headset/headpiece for use with cochlear implant device, replacement	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8617	Transmitting coil for use with cochlear implant device, replacement	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92601	PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
V5299	Hearing service	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
V5362	Speech screening	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92604	Reprogram cochlear implt 7/>	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
1999	ANESTHESIOLOGY GROUP	CPT	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92603	PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8619	PROCESSOR SOUND SONNET/RONDO 3 KT	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
92602	Reprogram cochlear implt <7	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
69949	Unlisted px inner ear	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8616	Microphone for use with cochlear implant device, replacement	HCPCS	POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC) 12/30/1999: Policy Guidelines updated 9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added 11/2001: Reviewed by MPAC; revisions approved 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added 3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added 7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated 10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted 3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added 03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy 03/13/2006: Policy reviewed, no changes 09/13/2006: Coding updated. ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated.
L8627	Cochlear implant, external speech processor, component, replacement	HCPCS	ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table.
L8628	Cochlear implant, external controller component, replacement	HCPCS	ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table.
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	HCPCS	ICD9 2006 revisions added to policy 12/27/2006: Code Reference section updated per the 2007 HCPCS revisions 3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table.
L8627	Cochlear implant, external speech processor, component, replacement	HCPCS	Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices.
L8628	Cochlear implant, external controller component, replacement	HCPCS	Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices.
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	HCPCS	Bilateral cochlear implantation added to Policy Guidelines section 06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary 7/19/2007: Reviewed and approved by MPAC 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices.
L8627	Cochlear implant, external speech processor, component, replacement	HCPCS	ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged.
L8628	Cochlear implant, external controller component, replacement	HCPCS	ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged.
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	HCPCS	ICD-9 2007 revisions added to policy 1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged.
L8627	Cochlear implant, external speech processor, component, replacement	HCPCS	3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines.
L8628	Cochlear implant, external controller component, replacement	HCPCS	3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines.
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	HCPCS	3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. Contraindications to cochlear implantation added to the policy guidelines.
1000	HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT	RC	Medically necessary policy statement updated to make correction: "100 HZ" updated to "1000 HZ." Policy Guidelines section updated regarding cochlear ossification and to add medically necessary and investigative definitions. 05/31/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.05 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
20694	Rmvl ext fixj sys under anes	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21206	Reconstruct upper jaw bone	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
42200	Reconstruct cleft palate	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D6199	PR UNSPEC IMPLANT PROCEDURE BY REPORT	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21196	Reconst lwr jaw w/fixation	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21247	Reconstruct lower jaw bone	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D8999	PR UNS ORTHODONTIC PROCEDURE BY REPORT	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20693	PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D8010	PR LTD ORTHODONT TX PRIMARY DENTITION	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
30462	Revision of nose	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21110	PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
0232T	Njx platelet plasma	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21210	PR GRAFT BONE NASAL/MAXILLARY/MALAR AREAS	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20696	PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT 1ST&SUBSQ	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
30400	Reconstruction of nose	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21120	Reconstruction of chin	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20692	PR APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
38220	PR DIAGNOSTIC BONE MARROW ASPIRATIONS	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D7949	Reconstruct midface w/graft	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
42225	Reconstruct cleft palate	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20697	PR APP MLTPLN UNI XTRNL FIX STRTCTC ADJMT EXCHANGE	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D6010	PR SURG PLCMT IMPL BODY: ENDOSTEAL	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
S9055	Procuren or other growth fac	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D7946	Reconstruction maxilla total	HCPCS	The mean follow-up time was 28.7 months. The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20694	Rmvl ext fixj sys under anes	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21206	Reconstruct upper jaw bone	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
42200	Reconstruct cleft palate	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D6199	PR UNSPEC IMPLANT PROCEDURE BY REPORT	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21196	Reconst lwr jaw w/fixation	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21247	Reconstruct lower jaw bone	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D8999	PR UNS ORTHODONTIC PROCEDURE BY REPORT	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
20693	PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
D8010	PR LTD ORTHODONT TX PRIMARY DENTITION	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
30462	Revision of nose	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|
21110	PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC	HCPCS	The authors concluded that in addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients. \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":\| \|ICD-10 codes will become effective as of October 1, 2015:\| \|CPT codes covered if selection criteria are met:\| \|20692\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)\| \|20693\|\|Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))\| \|20694\|\|Removal, under anesthesia, of external fixation system\| \|20696\|\|Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)\| \|20697\|\|exchange (ie, removal and replacement) of strut, each\| \|CPT codes not covered for indications listed in the CPB:\| \|0232T\|\|Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed\| \|Other CPT codes related to the CPB:\| \|21110\|\|Application of interdental fixation device for conditions other than fracture or dislocation, includes removal\| \|21120 - 21196\|\|Repair, revision, and/or reconstruction bones of face\| \|21206\|\|Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)\| \|21210\|\|Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)\| \|21247\|\|Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)\| \|30400 - 30462\|\|Rhinoplasty\| \|38220\|\|Bone marrow, aspiration only\| \|42200 - 42225\|\|Palatoplasty\| \|HCPCS codes not covered for indicationslisted in the CPB:\| \|S9055\|\|Procuren or other growth factor preparation to promote wound healing\| \|Other HCPCS codes related to the CPB:\| \|D6010 - D6199\|\|Implant services\| \|D7946 - D7949\|\|LeFort procedures I, II, or III\| \|D8010 - D8999\|\|Orthodontic dental procedures\| \|ICD-10 codes covered if selection criteria are met:\| \|M26.00 - M26.59\|\|Dentofacial anomalies [including malocclusion]\| \|Q35.1 - Q35.9\|\|Cleft palate\| \|Q37.0 - Q37.9\|\|Cleft palate with cleft lip\| \|Q67.0 - Q67.4\|\|Congenital deformities of skull, face and jaw\| \|Q75.0 - Q75.9\|\|Congenital malformation of skull and face bones [includes hemifacial microstomia]\| \|Q87.0\|\|Congenital malformation syndromes predominantly affecting facial appearance\| \|ICD-10 codes not covered for indications listed in the CPB:\| \|G47.33\|\|Obstructive sleep apnea (adult) (pediatric)\| \|M95.2\|\|Other acquired deformity of head [acquired craniofacial defects]\| \|Z41.1\|\|Encounter for cosmetic surgery\| \|Z46.3\|\|Encounter for fitting and adjustment of dental prosthetic device\| \|Z46.4\|\|Encounter for fitting and adjustment of orthodontic device\|

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