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36513 | PR THERAPEUTIC APHERESIS PLATELETS | 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 HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36512 | PR THERAPEUTIC APHERESIS RED BLOOD CELLS | 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 HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36521 | USE 36516 | 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 HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
36520 | SEE 36511-36512 | 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 HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36511 | PR THERAPEUTIC APHERESIS WHITE BLOOD CELLS | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36513 | PR THERAPEUTIC APHERESIS PLATELETS | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36512 | PR THERAPEUTIC APHERESIS RED BLOOD CELLS | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36521 | USE 36516 | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36520 | SEE 36511-36512 | HCPCS | POLICY HISTORY6/1993: Therapeutic Apheresis approved by Medical Policy Advisory Committee (MPAC)
11/1993: Extracorporeal Immunoadsorption Using Protein A Columns approved by MPAC
5/1999: MPAC reviewed policies; updated, combined and renamed
12/1999: Interim revision; new FDA-approved indication added for some stages of rheumatoid arthritis
2/2000: Interim revisions approved by MPAC
4/11/2001: Photopheresis for human heart transplant recipients at high risk for fatal rejection
8/2001: Reviewed by MPAC
2/13/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
10/4/2002: ICD-9 procedure code 99.76 added
3/5/2003: Code Reference section updated
7/2003: Reviewed by MPAC, policy aligned to be consistent with BCBSA, Sources updated
3/17/2004: Code Reference section updated, CPT code 36520, 36521 deleted, ICD-9 diagnosis code 203.0, 273.2, 282.8, 284.8, 356.3, 356.9, 358.00 (note 358.0 was covered), 391.1, 710.1, 710.4 deleted, HCPCS Q0068 deleted, ICD-9 diagnosis 642.5 fifth digit added
10/22/2004: Code Reference section updated, CPT 36511, 36512, 36513 deleted, ICD-9 diagnosis 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 272.0, 272.2, 273.0, 273.3, 283.11, 287.3, 287.4, 289.0, 341.0, 341.1, 341.8, 341.9, 357.0, 357.81, 358.01, 446.21, 446.6, 583.81, 642.50, 642.51, 642.52, 642.53, 642.54, 714.0, 714.1, 714.2, 714.30, 714.31, 714.32, 714.33, 714.4, 714.81, 714.89, 714.9, 996.83, E878.0 note added, ICD-9 diagnosis 340 deleted, HCPCS S2120 added
11/7/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 287.31
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
7/27/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC)
8/31/2006: Code Reference section updated. V42.0, V42.1,V42.6, V42.7, V42.81, V42.83 added to covered table
5/1/2008: Policy description updated with acute and chronic conditions; photopheresis, extracorporeal immunoadsorption, and lipid apheresis removed from policy. IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. |
36522 | PR PHOTOPHERESIS EXTRACORPOREAL | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
86960 | HC VOL REDUC BLD/PRD EA UN | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36516 | PR THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36515 | Apheresis adsorp/reinfuse | HCPCS | IgA or IgG paraproteinemia polyneuropathy added as a medically necessary indication. Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. |
36522 | PR PHOTOPHERESIS EXTRACORPOREAL | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
S2120 | Low density lipoprotein (ldl) apheresis using heparin-induced extracorporeal ldl precipitation | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
86960 | HC VOL REDUC BLD/PRD EA UN | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
36516 | PR THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
36515 | Apheresis adsorp/reinfuse | HCPCS | Inclusion body myositis and asthma added as investigational. Code reference section reviewed; CPT codes 36515, 36516, 36522, 86960 removed; ICD-9 procedure codes 99.76, 99.88 removed; ICD-9 diagnosis codes 202.20-202.28, 272.0-272.2, 714.0-714.9 removed; HCPCS S2120 removed. ICD-9 diagnosis codes 203.00, 203.01, 341.0, 341.20-341.22, 996.81, 996.82, 996.84-996.85 added
9/11/2008: Annual ICD-9 updates applied
06/23/2010: Policy Title changed, removed "Plasmapheresis." Policy Description section was revised for multiple reasons: definitions of apheresis, plasmapheresis and plasma exchange was added; addition applications of PE related to cryoglobulinemia, PANDAS and SC. Policy Statements (medically necessary and investigational) were revised to include conditions that may be considered medically necessary and conditions that are considered investigational. |
L5857 | Elec knee-shin swing only | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5858 | Stance phase only | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5856 | Elec knee-shin swing/stance | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5857 | Elec knee-shin swing only | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
L5858 | Stance phase only | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
L5856 | Elec knee-shin swing/stance | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. |
G0282 | HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE | HCPCS | Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. |
G0295 | Electromagnetic therapy onc | HCPCS | Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. |
G0282 | HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE | HCPCS | Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. |
G0295 | Electromagnetic therapy onc | HCPCS | Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. |
E0761 | Nontherm electromgntc device | HCPCS | The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. |
G0282 | HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE | HCPCS | The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. |
G0295 | Electromagnetic therapy onc | HCPCS | The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. |
E0761 | Nontherm electromgntc device | HCPCS | G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. |
G0295 | Electromagnetic therapy onc | HCPCS | G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. |
E0769 | Electric wound treatment dev | HCPCS | G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. |
E0761 | Nontherm electromgntc device | HCPCS | G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. |
E0769 | Electric wound treatment dev | HCPCS | G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. |
97032 | TENS APPLICATION CONSTANT SUP | HCPCS | G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. |
E0761 | Nontherm electromgntc device | HCPCS | E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. |
97032 | TENS APPLICATION CONSTANT SUP | HCPCS | E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. |
E0769 | Electric wound treatment dev | HCPCS | E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. The Medicare policy notes that coverage for electrical stimulation is limited to supervised settings. |
E0769 | Electric wound treatment dev | HCPCS | E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. The Medicare policy notes that coverage for electrical stimulation is limited to supervised settings. |
97032 | TENS APPLICATION CONSTANT SUP | HCPCS | E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. The Medicare policy notes that coverage for electrical stimulation is limited to supervised settings. |
G0281 | PR ELEC STIM UNATTEND FOR PRESS | HCPCS | The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. The Medicare policy notes that coverage for electrical stimulation is limited to supervised settings. Although the terminology is confusing, for the purposes of Medicare policy, supervised is interpreted to mean that while a physician or other health professional is supervising the treatment, this person does not have to be in constant attendance. |
97032 | TENS APPLICATION CONSTANT SUP | HCPCS | The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation. Attended electrical stimulation is identified by CPT code 97032. Although the description of this CPT code is nonspecific and could describe any type of electrical stimulation, electrical stimulation for wound healing would not require constant attendance, and thus the CPT code would not be applicable. The Medicare policy notes that coverage for electrical stimulation is limited to supervised settings. Although the terminology is confusing, for the purposes of Medicare policy, supervised is interpreted to mean that while a physician or other health professional is supervising the treatment, this person does not have to be in constant attendance. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | 2004; www.cms.hhs.gov. Accessed July, 2014. |CPT||See Policy Guidelines|
|ICD-9||707.00-707.9||Chronic ulcer of skin, code range|
|HCPCS||See Policy Guidelines|
|ICD-10-CM (effective 10/1/15)||Investigational for all wounds|
|E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622||Various types of diabetes with skin complications (foot ulcer or other skin ulcer) code list|
|I83.001-I83.029; I83.201-I83.229||Varicose veins with ulcer code range|
|L00 – L08.9||Infections of the skin code range (includes cellulitis – L03)|
|L89.00-L89.95||Pressure ulcer code range|
|L97.10-L97.929||Non-pressure chronic ulcer of skin code range|
|L98.41-L98.499||Non-pressure chronic ulcer of skin not otherwise classified code range|
|L99||Other disorders of skin and subcutaneous tissue in diseases classified elsewhere|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation or application of this therapy.|
Alternative Current (AC), Electrical Stimulation, Wounds Electrical Stimulation, Wounds
Electrostimulation and Electromagnetic Therapy
High Voltage Pulsed Current (HVPC)
Low Intensity Direct Current (LIDC), Wounds
Transcutaneous Electrical Nerve Stimulation (TENS), Treatment of Wounds
Ulcers, Electrical Stimulation
Wounds, Electrical Stimulation
|07/17/03||Add policy to Medicine section||New policy|
|04/1/05||Replace policy||Policy updated with February 2005 TEC Assessment; policy statement on electrical stimulation of wounds in now considered investigational. HCPCS code G0329 added to policy guidelines|
|04/25/06||Replace policy||Literature review update for the period of February 2005 through February 2006; reference number 4 added. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | Accessed July, 2014. |CPT||See Policy Guidelines|
|ICD-9||707.00-707.9||Chronic ulcer of skin, code range|
|HCPCS||See Policy Guidelines|
|ICD-10-CM (effective 10/1/15)||Investigational for all wounds|
|E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622||Various types of diabetes with skin complications (foot ulcer or other skin ulcer) code list|
|I83.001-I83.029; I83.201-I83.229||Varicose veins with ulcer code range|
|L00 – L08.9||Infections of the skin code range (includes cellulitis – L03)|
|L89.00-L89.95||Pressure ulcer code range|
|L97.10-L97.929||Non-pressure chronic ulcer of skin code range|
|L98.41-L98.499||Non-pressure chronic ulcer of skin not otherwise classified code range|
|L99||Other disorders of skin and subcutaneous tissue in diseases classified elsewhere|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation or application of this therapy.|
Alternative Current (AC), Electrical Stimulation, Wounds Electrical Stimulation, Wounds
Electrostimulation and Electromagnetic Therapy
High Voltage Pulsed Current (HVPC)
Low Intensity Direct Current (LIDC), Wounds
Transcutaneous Electrical Nerve Stimulation (TENS), Treatment of Wounds
Ulcers, Electrical Stimulation
Wounds, Electrical Stimulation
|07/17/03||Add policy to Medicine section||New policy|
|04/1/05||Replace policy||Policy updated with February 2005 TEC Assessment; policy statement on electrical stimulation of wounds in now considered investigational. HCPCS code G0329 added to policy guidelines|
|04/25/06||Replace policy||Literature review update for the period of February 2005 through February 2006; reference number 4 added. Policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature review; policy statement unchanged|
|05/08/08||Replace policy||Policy updated with literature review; references 5-7 added; policy statements unchanged|
|10/06/09||Replace policy||Policy updated with literature review; policy statement unchanged; reference 2 removed and others renumbered; new reference 7 added. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | |CPT||See Policy Guidelines|
|ICD-9||707.00-707.9||Chronic ulcer of skin, code range|
|HCPCS||See Policy Guidelines|
|ICD-10-CM (effective 10/1/15)||Investigational for all wounds|
|E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622||Various types of diabetes with skin complications (foot ulcer or other skin ulcer) code list|
|I83.001-I83.029; I83.201-I83.229||Varicose veins with ulcer code range|
|L00 – L08.9||Infections of the skin code range (includes cellulitis – L03)|
|L89.00-L89.95||Pressure ulcer code range|
|L97.10-L97.929||Non-pressure chronic ulcer of skin code range|
|L98.41-L98.499||Non-pressure chronic ulcer of skin not otherwise classified code range|
|L99||Other disorders of skin and subcutaneous tissue in diseases classified elsewhere|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation or application of this therapy.|
Alternative Current (AC), Electrical Stimulation, Wounds Electrical Stimulation, Wounds
Electrostimulation and Electromagnetic Therapy
High Voltage Pulsed Current (HVPC)
Low Intensity Direct Current (LIDC), Wounds
Transcutaneous Electrical Nerve Stimulation (TENS), Treatment of Wounds
Ulcers, Electrical Stimulation
Wounds, Electrical Stimulation
|07/17/03||Add policy to Medicine section||New policy|
|04/1/05||Replace policy||Policy updated with February 2005 TEC Assessment; policy statement on electrical stimulation of wounds in now considered investigational. HCPCS code G0329 added to policy guidelines|
|04/25/06||Replace policy||Literature review update for the period of February 2005 through February 2006; reference number 4 added. Policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature review; policy statement unchanged|
|05/08/08||Replace policy||Policy updated with literature review; references 5-7 added; policy statements unchanged|
|10/06/09||Replace policy||Policy updated with literature review; policy statement unchanged; reference 2 removed and others renumbered; new reference 7 added. Policy guidelines section revised.|
|10/08/10||Replace policy||Policy updated with literature review; no other changes to policy statements; Rationale rewritten; reference numbers 4-6 added.|
|10/11/12||Replace policy||Policy updated with literature review; policy statements unchanged. |
G0329 | PR ELECTROMAGNTIC TX FOR ULCERS | HCPCS | There is no specific ICD-10-PCS code for the initiation or application of this therapy.|
Alternative Current (AC), Electrical Stimulation, Wounds Electrical Stimulation, Wounds
Electrostimulation and Electromagnetic Therapy
High Voltage Pulsed Current (HVPC)
Low Intensity Direct Current (LIDC), Wounds
Transcutaneous Electrical Nerve Stimulation (TENS), Treatment of Wounds
Ulcers, Electrical Stimulation
Wounds, Electrical Stimulation
|07/17/03||Add policy to Medicine section||New policy|
|04/1/05||Replace policy||Policy updated with February 2005 TEC Assessment; policy statement on electrical stimulation of wounds in now considered investigational. HCPCS code G0329 added to policy guidelines|
|04/25/06||Replace policy||Literature review update for the period of February 2005 through February 2006; reference number 4 added. Policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature review; policy statement unchanged|
|05/08/08||Replace policy||Policy updated with literature review; references 5-7 added; policy statements unchanged|
|10/06/09||Replace policy||Policy updated with literature review; policy statement unchanged; reference 2 removed and others renumbered; new reference 7 added. Policy guidelines section revised.|
|10/08/10||Replace policy||Policy updated with literature review; no other changes to policy statements; Rationale rewritten; reference numbers 4-6 added.|
|10/11/12||Replace policy||Policy updated with literature review; policy statements unchanged. References 3 and 8 added; other references renumbered or removed.|
|10/10/13||Replace policy||Policy updated with literature review through September 5, 2013; policy statements unchanged. |
77781 | High Intensity Brachytherapy | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
76872 | US TRANS RECTAL | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77778 | HC ASRG INTERSTIT RADIOELEM APPLI | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
Q3001 | Radioelements for brachytherapy, any type, each | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77326 | Brachytx isodose calc simp | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
76873 | HC PROSTATE VOLUME STUDY | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
55860 | Surgical exposure prostate | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77784 | High Intensity Brachytherapy | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
55859 | Percut/needle insert, pros | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77761 | HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77763 | HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77776 | Apply interstit radiat simpl | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77790 | HC SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77762 | HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77328 | Brachytx isodose plan compl | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
C1717 | HC HDR NUCLETRON IRID 192 NON STN | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
76965 | Echo guidance radiotherapy | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
55876 | PR PLMT INTERSTITIAL DEV RADIAT TX PROSTATE 1/MULT | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. |
77326 | Brachytx isodose calc simp | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77783 | High Intensity Brachytherapy | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77790 | HC SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77762 | HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
76965 | Echo guidance radiotherapy | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
55876 | PR PLMT INTERSTITIAL DEV RADIAT TX PROSTATE 1/MULT | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
76872 | US TRANS RECTAL | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
Q3001 | Radioelements for brachytherapy, any type, each | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
C1717 | HC HDR NUCLETRON IRID 192 NON STN | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77781 | High Intensity Brachytherapy | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77778 | HC ASRG INTERSTIT RADIOELEM APPLI | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
55860 | Surgical exposure prostate | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
55859 | Percut/needle insert, pros | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77761 | HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77328 | Brachytx isodose plan compl | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
76873 | HC PROSTATE VOLUME STUDY | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77784 | High Intensity Brachytherapy | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77782 | High Intensity Brachytherapy | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
77763 | HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX | HCPCS | POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008. 07/29/2011: Policy reviewed; no changes. |
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