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61635 | PR TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD | HCPCS | If knowledge of the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure. The American Institute of Ultrasound in Medicine’s practice guideline on “Transcranial Doppler ultrasound for adults and children” (2012) listed “detection of right-to-left shunts’ as one of the indications for a TCD ultrasound examination of adults. |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93893 | Tcd emboli detect w/inj | HCPCS | The American Institute of Ultrasound in Medicine’s practice guideline on “Transcranial Doppler ultrasound for adults and children” (2012) listed “detection of right-to-left shunts’ as one of the indications for a TCD ultrasound examination of adults. |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93886 | PR TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL | HCPCS | The American Institute of Ultrasound in Medicine’s practice guideline on “Transcranial Doppler ultrasound for adults and children” (2012) listed “detection of right-to-left shunts’ as one of the indications for a TCD ultrasound examination of adults. |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93892 | Tcd emboli detect w/o inj | HCPCS | The American Institute of Ultrasound in Medicine’s practice guideline on “Transcranial Doppler ultrasound for adults and children” (2012) listed “detection of right-to-left shunts’ as one of the indications for a TCD ultrasound examination of adults. |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
61635 | PR TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD | HCPCS | The American Institute of Ultrasound in Medicine’s practice guideline on “Transcranial Doppler ultrasound for adults and children” (2012) listed “detection of right-to-left shunts’ as one of the indications for a TCD ultrasound examination of adults. |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93893 | Tcd emboli detect w/inj | HCPCS | |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93886 | PR TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL | HCPCS | |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
93892 | Tcd emboli detect w/o inj | HCPCS | |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
61635 | PR TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD | HCPCS | |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:|
|93886||Transcranial Doppler study of the intracranial arteries; complete study|
|93892||emboli detection without intravenous microbubble injection|
|93893||emboli detection with intravenous microbubble injection|
|Other CPT codes related to the CPB:|
|61635||Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed|
|ICD-10 codes covered if selection criteria are met:|
|D57.00 - D57.819||Sickle-cell disorders [for evaluating children]|
|G93.1||Anoxic brain damage, not elsewhere classified|
|G93.5||Compression of brain|
|H34.00 - H34.9||Retinal vascular occlusions|
|H53.10||unspecified subjective visual disturbances|
|H53.121 - H53.129||Transient visual loss|
|H53.131 - H53.139||Sudden visual loss|
|I28.0||Arteriovenous fistula of pulmonary vessels [for detecting noncardiac right-to-left shunts]|
|I60.00 - I65.9, I67.0 - I69.998||Cerebrovascular diseases|
|I77.1||Stricture of artery|
|I77.74||Dissection of vertebral artery|
|I74.9||Embolism and thrombosis of unspecified artery [paradoxical embolism]|
|P05.00 - P05.9||Disorders of newborn related to slow fetal growth and fetal malnutrition|
|P07.00 - P07.32||Disorders of newborn related to short gestation and low birth weight, not elsewhere classified|
|Q21.1||Atrial septal defect [patent foramen ovale]|
|Q25.6||Stenosis of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q25.79||Other congenital malformations of pulmonary artery [for detecting noncardiac right-to-left shunts]|
|Q28.0 - Q28.9||Other congenital malformations of circulatory system [arteriovenous malformation (AVM)]|
|R40.4||Transient alteration of awareness|
|R47.01 - R47.02||Aphasia and dysphasia|
|R47.1||Dysarthria and anarthria|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C71.0 - C71.9||Malignant neoplasm of brain|
|C79.31 - C79.49||Secondary malignant neoplasm of brain and nervous system [spinal cord]|
|D33.0 - D33.2||Benign neoplasm of brain|
|D43.0 - D43.4||Neoplasm of uncertain behavior of brain and spinal cord|
|D49.6||Neoplasm of unspecified behavior of brain|
|E75.00 - E75.19
|Disorders of sphingolipid metabolism and other lipid storage disorders|
|F01.50 - F99||Mental and behavioral disorders|
|G00.0 - G09||Inflammatory diseases of the central nervous system|
|G10 - G12.9, G13.8||Systemic atrophies primarily affecting the central nervous system|
|G20 - G26||Extrapyramidal and movement disorders|
|G30.0 - G32.8||Other degenerative diseases of the nervous system|
|G40.00 - G40.919||Epilepsy and recurrent seizures|
|G43.001 - G43.919||Migraine|
|G80.3||Athetoid cerebral palsy|
|G90.01 - G91.9||Other disorders of the nervous system|
|G93.89 - G93.9, G94||Other and unspecified disorders of the brain|
|G95.0 - G95.9||Other and unspecified diseases of spinal cord|
|G99.0 - G99.8||Other disorders of nervous system in diseases classified elsewhere|
|I63. 30 - I63.39, I66.01 - I66.9||Cerebral thrombosis|
|I72.0 - I72.9||Other aneurysm|
|I77.3||Arterial fibromuscular dysplasia|
|Q85.00 - Q85.9||Neurofibromatosis (nonmalignant) [in children]|
|R56.1||Post traumatic seizures|
|Z13.6||Encounter for screening for cardiovascular disorders [screening for carotid artery stenosis in asymptomatic persons]|
|Z79.01||Long-term (current) use of anticoagulants|
|Z79.02||Long-term (current) use of antiplatelets/antithrombotics| |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0362 | Each add sequential infusion | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86826 | Hla x-match noncytotoxc addl | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86825 | X-MATCHAHG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38241 | Transplt autol hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38240 | Transplt allo hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0265 | Cryopresevation Freeze+stora | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38242 | Transplt allo lymphocytes | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0266 | Thawing + expansion froz cel | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96445 | Chemotherapy, intracavitary | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0267 | Bone marrow or psc harvest | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0267 | Bone marrow or psc harvest | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0267 | Bone marrow or psc harvest | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0265 | Cryopresevation Freeze+stora | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
38242 | Transplt allo lymphocytes | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G0266 | Thawing + expansion froz cel | CPT | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G6015 | Radiation tx delivery imrt | HCPCS | IMRT remains investigational for all other uses in the abdomen and pelvis. Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. |
77386 | HC IMRT COMPLEX | HCPCS | IMRT remains investigational for all other uses in the abdomen and pelvis. Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. |
77385 | HC IMRT SIMPLE | HCPCS | IMRT remains investigational for all other uses in the abdomen and pelvis. Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | IMRT remains investigational for all other uses in the abdomen and pelvis. Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. |
G6015 | Radiation tx delivery imrt | HCPCS | Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. |
77386 | HC IMRT COMPLEX | HCPCS | Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. |
77385 | HC IMRT SIMPLE | HCPCS | Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Policy guidelines updated regarding radiation tolerance doses for normal tissues of the abdomen and pelvis. 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. |
G6015 | Radiation tx delivery imrt | HCPCS | 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." |
77386 | HC IMRT COMPLEX | HCPCS | 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." |
77385 | HC IMRT SIMPLE | HCPCS | 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." |
G6016 | PR DELIVERY COMP IMRT | HCPCS | 03/13/2014: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." |
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