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82465 | HC CHOLESTEROL LEVEL W/DIRECT LDL | HCPCS | Code 33871’s descriptor better describes the way the procedure is performed now. Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. |
33871 | Transvrs a-arch grf hypthrm | HCPCS | Code 33871’s descriptor better describes the way the procedure is performed now. Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. |
80061 | TTH LIPID-SP | HCPCS | Code 33871’s descriptor better describes the way the procedure is performed now. Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. |
G0446 | PR INTENS BEHAVE THER CARDIO DX | HCPCS | Code 33871’s descriptor better describes the way the procedure is performed now. Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. |
83718 | LIPOPROTEIN, DIRECT MEASUREMENT_ HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) | HCPCS | Code 33871’s descriptor better describes the way the procedure is performed now. Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. |
82465 | HC CHOLESTEROL LEVEL W/DIRECT LDL | HCPCS | Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. |
80061 | TTH LIPID-SP | HCPCS | Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. |
83718 | LIPOPROTEIN, DIRECT MEASUREMENT_ HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) | HCPCS | Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. |
G0446 | PR INTENS BEHAVE THER CARDIO DX | HCPCS | Medicare Coverage of Screening for Heart Disease
There are two Medicare-covered preventative services for heart disease screening per national coverage determination (NCD) 210.11: “Cardiovascular Disease Screening Tests” and “Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD).”
If you are a Medicare patient and don’t have apparent signs or symptoms of CVD, you are still covered once every five years for cardiovascular disease screening tests. These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. |
82465 | HC CHOLESTEROL LEVEL W/DIRECT LDL | HCPCS | These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. |
8006 | CT and CTA with Contrast | APC | These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. |
80061 | TTH LIPID-SP | HCPCS | These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. |
G0446 | PR INTENS BEHAVE THER CARDIO DX | HCPCS | These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. |
83718 | LIPOPROTEIN, DIRECT MEASUREMENT_ HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) | HCPCS | These tests are reported using CPT® code:
80061 Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) (83718)
ICD-10-CM code Z13.6 Encounter for screening for cardiovascular disorders supports 80061; however, other codes may apply, as well. To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. |
G0446 | PR INTENS BEHAVE THER CARDIO DX | HCPCS | To see Change Requests (CRs) specific to individual ICD-10 codes for screening for cardiovascular disorders, go to the Centers for Medicare & Medicaid Services’ (CMS) Medicare Coverage – General Information ICD-10 webpage. According to NCD 210.11, IBT for CVD is covered annually for Medicare patients “who are competent and alert at the time counseling is provided” and if the counseling is furnished “by a qualified primary care physician or other primary care practitioner in a primary care setting.” Coding for the CVD risk reduction visit includes HCPCS Level II G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. To see CRs specific to individual ICD-10 codes for IBT for CVD, go to the CMS Medicare Coverage – General Information ICD-10 webpage. More Heart Smart Resources
You can find more heart conscious resource links in the weekly MLN Connects, some of them include:
- Medicare Preventive Services Educational Tool
- Million Hearts®: An HHS initiative to prevent a million heart attacks and strokes
- Centers for Disease Control and Prevention Heart Disease website
- American Heart Month webpage
Prove Your Heart Expertise
AAPC has two credentials that can help prove your know-how in cardiovascular coding. Go to AAPC’s Certified Cardiovascular and Thoracic Surgery Coder (CCVTC™) and Certified Interventional Radiology Cardiovascular Coder (CIRCC®) credential pages to find out more. |
97533 | Therapy procedure using sensory experiences | HCPCS | Studies of sensory-based interventions suggested that they may not be effective; however, they did not follow recommended protocols or target sensory processing problems. The authors concluded that although small RCTs resulted in positive effects for SIT, additional rigorous trials using manualized protocols for SIT are needed to evaluate effects for children with ASDs and sensory processing problems. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|299.00 - 299.91||Pervasive developmental disorders|
|307.9||Other and unspecified special symptoms or syndromes, not elsewhere classified [communication disorder]|
|309.3||Adjustment disorder with disturbance of conduct|
|312.00 - 312.9||Disturbance of conduct, not elsewhere classified|
|313.0 - 313.9||Disturbance of emotions specific to childhood and adolescence|
|314.00 - 314.9||Hyperkinetic syndrome of childhood|
|315.00 - 315.9||Specific delays in development|
|759.83||Fragile X syndrome|
|783.40 - 783.43||Lack of expected normal physiological development in childhood|
|V40.0 - V40.9||Mental and behavioral problems|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F43.20 - F43.29||Adjustment disorders|
|F80.9||Developmental disorder of speech and language, unspecified [communication disorder]|
|F81.0 - F81.9||Specific developmental disorders of scholastic skills|
|F84.0 - F84.9||Pervasive developmental disorders|
|F90.0 - F90.9||Attention-deficit hyperactivity disorders|
|F91.0 - F91.9||Conduct diorders|
|F93.0 - F93.9||Emotional disorders with onset specific to childhood|
|Q99.2||Fragile X chromosome|
|R62.50||Unspecified lack of expected normal physiological development in childhood|
|Z03.89||Encounter for observation for other suspected diseases and conditions ruled out [Observation for suspected mental condition]| |
97533 | Therapy procedure using sensory experiences | HCPCS | The authors concluded that although small RCTs resulted in positive effects for SIT, additional rigorous trials using manualized protocols for SIT are needed to evaluate effects for children with ASDs and sensory processing problems. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|299.00 - 299.91||Pervasive developmental disorders|
|307.9||Other and unspecified special symptoms or syndromes, not elsewhere classified [communication disorder]|
|309.3||Adjustment disorder with disturbance of conduct|
|312.00 - 312.9||Disturbance of conduct, not elsewhere classified|
|313.0 - 313.9||Disturbance of emotions specific to childhood and adolescence|
|314.00 - 314.9||Hyperkinetic syndrome of childhood|
|315.00 - 315.9||Specific delays in development|
|759.83||Fragile X syndrome|
|783.40 - 783.43||Lack of expected normal physiological development in childhood|
|V40.0 - V40.9||Mental and behavioral problems|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|F43.20 - F43.29||Adjustment disorders|
|F80.9||Developmental disorder of speech and language, unspecified [communication disorder]|
|F81.0 - F81.9||Specific developmental disorders of scholastic skills|
|F84.0 - F84.9||Pervasive developmental disorders|
|F90.0 - F90.9||Attention-deficit hyperactivity disorders|
|F91.0 - F91.9||Conduct diorders|
|F93.0 - F93.9||Emotional disorders with onset specific to childhood|
|Q99.2||Fragile X chromosome|
|R62.50||Unspecified lack of expected normal physiological development in childhood|
|Z03.89||Encounter for observation for other suspected diseases and conditions ruled out [Observation for suspected mental condition]| |
86891 | HC AUTOLOGOUS BLOOD SALVAGED | HCPCS | The authors concluded that these findings support the notion that the IOCS-LDF combination works effectively in eliminating tumor cells from salvaged blood, so this technique can be applied successfully in spine tumor surgery. They stated that this concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-9 codes covered if selection criteria are met (not all-inclusive):|
|285.1||Acute posthemorrhagic anemia|
|633.00 - 633.91||Ectopic pregnancy|
|639.1||Delayed or excessive hemorrhage|
|641.11, 641.13||Hemorrhage from placenta previa|
|641.31, 641.33||Antepartum hemorrhage associated with coagulation defects|
|641.81, 641.83||Other antepartum hemorrhage|
|666.02, 666.04||Third-stage postpartum hemorrhage|
|666.12, 666.14||Other immediate postpartum hemorrhage|
|666.22, 666.24||Delayed and secondary postpartum hemorrhage|
|674.32, 674.34||Other complications of obstetrical surgical wounds|
|786.31||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|860.0 - 860.5||Traumatic pneumothorax and hemothorax|
|996.80 - 996.89||Complications of transplanted organ|
|997.69||Other amputation stump complication|
|997.71 - 997.79||Vascular complications of other vessels|
|998.11||Hemorrhage complicating a procedure|
|998.2||Accidental puncture or laceration during a procedure|
|998.31 - 998.32||Disruption of operation wound|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D62||Acute posthemorrhagic anemia|
|O00.0 - O00.9||Ectopic pregnancy|
|O08.1||Delayed or excessive hemorrhage following ectopic and molar pregnancy|
|O44.10 - O44.13||Placenta previa with hemorrhage|
|O45.001 - O45.099||Premature separation of placenta with coagulation defect|
|O46.001 - O46.099||Antepartum hemorrhage with coagulation defect|
|O67.0||Intrapartum hemorrhage with coagulation defect|
|O72.1||Other immediate postpartum hemorrhage|
|O72.2||Delayed and secondary postpartum hemorrhage|
|O90.2||Hematoma of obstetric wound|
|R04.81||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|R04.89||Hemorrhage from other sites in respiratory passages|
|R04.9||Hemorrhage from respiratory passages, unspecified|
|R58||Hemorrhage, not elsewhere classified|
|S27.0xx+ - S27.2xx+||Traumatic pneumothorax, hemothorax and hemopneumothorax|
|T81.30x+ - T81.33x+||Disruption of wound, not elsewhere classified|
|T81.710+ - T81.72x+||Vascular complications following a procedure, not elsewhere classified|
|T86.00 - T86.99||Complications of transplanted organs and tissue|
|T87.30 - T87.9||Other complications of amputation stump|
|Numerous options||Accidental puncture or laceration during a procedure [Codes not listed due to expanded specificity]|
|Numerous options||Hemorrhage complicating a procedure [Codes not listed due to expanded specificity]| |
86890 | HC AUTOLOGOUS BLOOD PRE-DEPOSITED | HCPCS | The authors concluded that these findings support the notion that the IOCS-LDF combination works effectively in eliminating tumor cells from salvaged blood, so this technique can be applied successfully in spine tumor surgery. They stated that this concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-9 codes covered if selection criteria are met (not all-inclusive):|
|285.1||Acute posthemorrhagic anemia|
|633.00 - 633.91||Ectopic pregnancy|
|639.1||Delayed or excessive hemorrhage|
|641.11, 641.13||Hemorrhage from placenta previa|
|641.31, 641.33||Antepartum hemorrhage associated with coagulation defects|
|641.81, 641.83||Other antepartum hemorrhage|
|666.02, 666.04||Third-stage postpartum hemorrhage|
|666.12, 666.14||Other immediate postpartum hemorrhage|
|666.22, 666.24||Delayed and secondary postpartum hemorrhage|
|674.32, 674.34||Other complications of obstetrical surgical wounds|
|786.31||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|860.0 - 860.5||Traumatic pneumothorax and hemothorax|
|996.80 - 996.89||Complications of transplanted organ|
|997.69||Other amputation stump complication|
|997.71 - 997.79||Vascular complications of other vessels|
|998.11||Hemorrhage complicating a procedure|
|998.2||Accidental puncture or laceration during a procedure|
|998.31 - 998.32||Disruption of operation wound|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D62||Acute posthemorrhagic anemia|
|O00.0 - O00.9||Ectopic pregnancy|
|O08.1||Delayed or excessive hemorrhage following ectopic and molar pregnancy|
|O44.10 - O44.13||Placenta previa with hemorrhage|
|O45.001 - O45.099||Premature separation of placenta with coagulation defect|
|O46.001 - O46.099||Antepartum hemorrhage with coagulation defect|
|O67.0||Intrapartum hemorrhage with coagulation defect|
|O72.1||Other immediate postpartum hemorrhage|
|O72.2||Delayed and secondary postpartum hemorrhage|
|O90.2||Hematoma of obstetric wound|
|R04.81||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|R04.89||Hemorrhage from other sites in respiratory passages|
|R04.9||Hemorrhage from respiratory passages, unspecified|
|R58||Hemorrhage, not elsewhere classified|
|S27.0xx+ - S27.2xx+||Traumatic pneumothorax, hemothorax and hemopneumothorax|
|T81.30x+ - T81.33x+||Disruption of wound, not elsewhere classified|
|T81.710+ - T81.72x+||Vascular complications following a procedure, not elsewhere classified|
|T86.00 - T86.99||Complications of transplanted organs and tissue|
|T87.30 - T87.9||Other complications of amputation stump|
|Numerous options||Accidental puncture or laceration during a procedure [Codes not listed due to expanded specificity]|
|Numerous options||Hemorrhage complicating a procedure [Codes not listed due to expanded specificity]| |
86891 | HC AUTOLOGOUS BLOOD SALVAGED | HCPCS | They stated that this concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-9 codes covered if selection criteria are met (not all-inclusive):|
|285.1||Acute posthemorrhagic anemia|
|633.00 - 633.91||Ectopic pregnancy|
|639.1||Delayed or excessive hemorrhage|
|641.11, 641.13||Hemorrhage from placenta previa|
|641.31, 641.33||Antepartum hemorrhage associated with coagulation defects|
|641.81, 641.83||Other antepartum hemorrhage|
|666.02, 666.04||Third-stage postpartum hemorrhage|
|666.12, 666.14||Other immediate postpartum hemorrhage|
|666.22, 666.24||Delayed and secondary postpartum hemorrhage|
|674.32, 674.34||Other complications of obstetrical surgical wounds|
|786.31||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|860.0 - 860.5||Traumatic pneumothorax and hemothorax|
|996.80 - 996.89||Complications of transplanted organ|
|997.69||Other amputation stump complication|
|997.71 - 997.79||Vascular complications of other vessels|
|998.11||Hemorrhage complicating a procedure|
|998.2||Accidental puncture or laceration during a procedure|
|998.31 - 998.32||Disruption of operation wound|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D62||Acute posthemorrhagic anemia|
|O00.0 - O00.9||Ectopic pregnancy|
|O08.1||Delayed or excessive hemorrhage following ectopic and molar pregnancy|
|O44.10 - O44.13||Placenta previa with hemorrhage|
|O45.001 - O45.099||Premature separation of placenta with coagulation defect|
|O46.001 - O46.099||Antepartum hemorrhage with coagulation defect|
|O67.0||Intrapartum hemorrhage with coagulation defect|
|O72.1||Other immediate postpartum hemorrhage|
|O72.2||Delayed and secondary postpartum hemorrhage|
|O90.2||Hematoma of obstetric wound|
|R04.81||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|R04.89||Hemorrhage from other sites in respiratory passages|
|R04.9||Hemorrhage from respiratory passages, unspecified|
|R58||Hemorrhage, not elsewhere classified|
|S27.0xx+ - S27.2xx+||Traumatic pneumothorax, hemothorax and hemopneumothorax|
|T81.30x+ - T81.33x+||Disruption of wound, not elsewhere classified|
|T81.710+ - T81.72x+||Vascular complications following a procedure, not elsewhere classified|
|T86.00 - T86.99||Complications of transplanted organs and tissue|
|T87.30 - T87.9||Other complications of amputation stump|
|Numerous options||Accidental puncture or laceration during a procedure [Codes not listed due to expanded specificity]|
|Numerous options||Hemorrhage complicating a procedure [Codes not listed due to expanded specificity]| |
86890 | HC AUTOLOGOUS BLOOD PRE-DEPOSITED | HCPCS | They stated that this concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-9 codes covered if selection criteria are met (not all-inclusive):|
|285.1||Acute posthemorrhagic anemia|
|633.00 - 633.91||Ectopic pregnancy|
|639.1||Delayed or excessive hemorrhage|
|641.11, 641.13||Hemorrhage from placenta previa|
|641.31, 641.33||Antepartum hemorrhage associated with coagulation defects|
|641.81, 641.83||Other antepartum hemorrhage|
|666.02, 666.04||Third-stage postpartum hemorrhage|
|666.12, 666.14||Other immediate postpartum hemorrhage|
|666.22, 666.24||Delayed and secondary postpartum hemorrhage|
|674.32, 674.34||Other complications of obstetrical surgical wounds|
|786.31||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|860.0 - 860.5||Traumatic pneumothorax and hemothorax|
|996.80 - 996.89||Complications of transplanted organ|
|997.69||Other amputation stump complication|
|997.71 - 997.79||Vascular complications of other vessels|
|998.11||Hemorrhage complicating a procedure|
|998.2||Accidental puncture or laceration during a procedure|
|998.31 - 998.32||Disruption of operation wound|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|86890||Autologous blood or component, collection processing and storage; predeposited|
|86891||intra- or postoperative salvage|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D62||Acute posthemorrhagic anemia|
|O00.0 - O00.9||Ectopic pregnancy|
|O08.1||Delayed or excessive hemorrhage following ectopic and molar pregnancy|
|O44.10 - O44.13||Placenta previa with hemorrhage|
|O45.001 - O45.099||Premature separation of placenta with coagulation defect|
|O46.001 - O46.099||Antepartum hemorrhage with coagulation defect|
|O67.0||Intrapartum hemorrhage with coagulation defect|
|O72.1||Other immediate postpartum hemorrhage|
|O72.2||Delayed and secondary postpartum hemorrhage|
|O90.2||Hematoma of obstetric wound|
|R04.81||Acute idiopathic pulmonary hemorrhage in infants [AIPHI]|
|R04.89||Hemorrhage from other sites in respiratory passages|
|R04.9||Hemorrhage from respiratory passages, unspecified|
|R58||Hemorrhage, not elsewhere classified|
|S27.0xx+ - S27.2xx+||Traumatic pneumothorax, hemothorax and hemopneumothorax|
|T81.30x+ - T81.33x+||Disruption of wound, not elsewhere classified|
|T81.710+ - T81.72x+||Vascular complications following a procedure, not elsewhere classified|
|T86.00 - T86.99||Complications of transplanted organs and tissue|
|T87.30 - T87.9||Other complications of amputation stump|
|Numerous options||Accidental puncture or laceration during a procedure [Codes not listed due to expanded specificity]|
|Numerous options||Hemorrhage complicating a procedure [Codes not listed due to expanded specificity]| |
E0755 | Electronic salivary reflex s | HCPCS | There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjogren's syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|HCPCS codes not covered for indications listed in the CPB:|
|E0755||Electronic salivary reflex stimulator (intraoral/noninvasive)|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|521.00 - 521.09||Dental caries|
|527.7||Disturbance of salivary secretion (xerostomia)|
|528.9||Other and unspecified diseases of oral soft tissues|
|710.2||Sicca syndrome [Sjogren's disease]|
|787.20 - 787.29||Dysphagia|
|990||Effects of radiation, unspecified [radiation-induced xerostomia]|
|V15.3||Personal history of irradiation|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|HCPCS codes not covered for indications listed in the CPB:|
|E0755||Electronic salivary reflex stimulator (intraoral/noninvasive)|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|K02.3 - K02.9
|Dental caries and other specified diseases of hard tissues of teeth|
|K11.7||Disturbance of salivary secretion (xerostomia)|
K13.6 - K13.79
|Other and unspecified diseases of oral soft tissues|
|M35.00 - M35.09||Sicca syndrome [Sjegren]|
|R13.10 - R13.19||Dysphagia|
|T66.xx+||Effects of radiation, unspecified [radiation-induced xerostomia]|
|Z92.3||Personal history of irradiation| |
E0755 | Electronic salivary reflex s | HCPCS | Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|HCPCS codes not covered for indications listed in the CPB:|
|E0755||Electronic salivary reflex stimulator (intraoral/noninvasive)|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|521.00 - 521.09||Dental caries|
|527.7||Disturbance of salivary secretion (xerostomia)|
|528.9||Other and unspecified diseases of oral soft tissues|
|710.2||Sicca syndrome [Sjogren's disease]|
|787.20 - 787.29||Dysphagia|
|990||Effects of radiation, unspecified [radiation-induced xerostomia]|
|V15.3||Personal history of irradiation|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|HCPCS codes not covered for indications listed in the CPB:|
|E0755||Electronic salivary reflex stimulator (intraoral/noninvasive)|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|K02.3 - K02.9
|Dental caries and other specified diseases of hard tissues of teeth|
|K11.7||Disturbance of salivary secretion (xerostomia)|
K13.6 - K13.79
|Other and unspecified diseases of oral soft tissues|
|M35.00 - M35.09||Sicca syndrome [Sjegren]|
|R13.10 - R13.19||Dysphagia|
|T66.xx+||Effects of radiation, unspecified [radiation-induced xerostomia]|
|Z92.3||Personal history of irradiation| |
G0206 | Dx mammo incl cad uni | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. |
77063 | Screening 3D breast mammography | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. |
G0204 | Dx mammo incl cad bi | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. |
G0206 | Dx mammo incl cad uni | 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 HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | 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 HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. |
77063 | Screening 3D breast mammography | 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 HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. |
G0204 | Dx mammo incl cad bi | 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 HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | 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 HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. |
G0206 | Dx mammo incl cad uni | HCPCS | POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. |
77063 | Screening 3D breast mammography | HCPCS | POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. |
G0204 | Dx mammo incl cad bi | HCPCS | POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | POLICY HISTORY4/9/2007: Policy added
5/11/2007: Bancorp South (C427, C445, C458, and C550) policy exception added
7/19/2007: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)
5/9/2008: Policy reviewed, no changes
05/08/2013: Policy reviewed; no changes. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. |
G0206 | Dx mammo incl cad uni | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. 07/13/2015: Code Reference section updated for ICD-10. |
77062 | MM MAMMO TOMOSYNTHESIS BILATERAL | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. 07/13/2015: Code Reference section updated for ICD-10. |
77063 | Screening 3D breast mammography | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. 07/13/2015: Code Reference section updated for ICD-10. |
G0204 | Dx mammo incl cad bi | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. 07/13/2015: Code Reference section updated for ICD-10. |
77061 | HC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77061, 77062, and 77063. Revised the description of the following HCPCS codes with an effective date of 01/01/2015: G0204 and G0206. 04/27/2015: Removed CPT codes 77061, 77062, and 77063 from the Code Reference section. These procedures are specifically addressed by the Digital Breast Tomosynthesis medical policy guidelines. 07/13/2015: Code Reference section updated for ICD-10. |
83015 | Heavy metal qual any anal | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
96365 | PR IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0895 | INJECTION, DEFEROXAMINE MESYLATE, 500 MG | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0470 | Injection, dimercaprol, per 100 mg | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0600 | Injection, edetate calcium disodium, up to 1000 mg | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J3520 | EDETATE DISODIUM POWDER | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
96368 | THER/DIAG CONCURRENT INF | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
S9355 | HIT chelation diem | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
M0300 | Iv chelationtherapy | HCPCS | The authors concluded that given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
83015 | Heavy metal qual any anal | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
96365 | PR IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0895 | INJECTION, DEFEROXAMINE MESYLATE, 500 MG | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0470 | Injection, dimercaprol, per 100 mg | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J0600 | Injection, edetate calcium disodium, up to 1000 mg | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
J3520 | EDETATE DISODIUM POWDER | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
96368 | THER/DIAG CONCURRENT INF | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
S9355 | HIT chelation diem | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
M0300 | Iv chelationtherapy | HCPCS | Moreover, they stated that before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|Other CPT codes related to the CPB:|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes covered if selection criteria are met:|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|ICD-10 codes covered if selection criteria are met:|
|D46.22||Refractory anemia with excess of blasts 2|
|D46.9||Myelodysplastic syndrome, unspecified|
|D46.C||Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality|
|D46.Z||Other myelodysplastic syndromes|
|D56.0 - D56.9||Thalassemia|
|D57.00 - D57.819||Sickle-cell disorders|
|D61.01||Constitutional (pure) red blood cell aplasia [Blackfan-Diamond syndrome]|
|E83.10, E83.19||Other and unspecified disorders of iron metabolism|
|E83.111||Hemochromatosis due to repeated red blood cell transfusions|
|K74.3 - K74.5||Biliary cirrhosis|
|N18.6||End stage renal disease [due to iron overload from multiple transfusions]|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T39.4X1+ - T39.4X6+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds [not covered for treatment of (mercury toxicity) from dental amalgam fillings]|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0X1+ - T57.0X4+||Toxic effect of arsenic and its compounds|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|A69.20 - A69.29||Lyme disease|
|B46.0 - B46.9||Zygomycosis|
|C00.0 - C96.9||Malignant neoplasm|
|D00.00 - D09.9||Carcinoma in situ|
|Diabetic cataract (Type I and Type II)|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder|
|G10 - G12.9, G13.8, G20 - G23.9
G24.02 - G26, G30 - G31.09, G31.2, G31.83 - G31.9, G80.3, G90.09, G91.0 - G91.9, G93.7, G94, G95.81 - G95.9
|Hereditary and degenerative diseases of the central nervous system|
|G93.3||Postviral fatigue syndrome|
|I00 - I52||Diseases of the circulatory system|
|I70.201 - I70.299||Atherosclerosis of native arteries of the extremities|
|I70.301 - I70.799||Atherosclerosis of bypass graft of the extremities|
|I70.8||Atherosclerosis of other arteries|
|I70.90 - I70.91||Unspecified and generalized atherosclerosis|
|I73.00 - I73.9||Other peripheral vascular diseases|
|R53.0 - R53.83||Malaise and fatigue|
|Z41.8 - Z41.9||Encounter for other and unspecified procedures for purposes other than remedying health state [prevention of cardiovascular disease]|
|Z98.61||Coronary angioplasty status|
|Laboratory tests for heavy metal poisoning:|
|CPT codes covered if selection criteria are met:|
|83015||Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|D80.0 - D80.9||Immunodeficiency with predominantly antibody defects|
|F50.8||Other eating disorders [pica in adults]|
|F80.0 - F82||Specific developmental disorders of speech and language|
|F91.9||Conduct disorder, unspecified|
|F98.3||Pica of infancy and childhood|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H90.8||Conductive and sensorineural hearing loss|
|H91.01 - H91.93||Other and unspecified hearing loss|
|K05.00 - K05.6||Gingivitis and periodontal diseases|
|K11.7||Disturbances of salivary secretion|
|K52.0 - K52.9||Other and unspecified noninfective gastroenteritis and colitis|
|K59.00 - K59.09||Constipation|
|L29.8 - L29.9||Other and unspecified pruritis|
|M62.81||Muscle weakness (generalized)|
|N05.0 - N05.9||Unspecified nephritic syndrome|
|N28.9||Disorder of kidney and ureter, unspecified|
|R10.0 - R10.33||Abdominal and pelvic pain|
|R11.0 - R11.2||Nausea and vomiting|
|R20.0 - R20.9||Disturbances of skin sensation|
|R21||Rash and other nonspecific skin eruption|
|R22.0 - R22.9||Localized superficial swelling, mass and lump of skin and subcutaneous tissue|
|R23.4||Changes in skin texture|
|R25.0 - R25.9||Abnormal involuntary movements|
|R34||Anuria and oliguria|
|R40.20 - R40.4||Coma|
|R41.1 - R41.3||Amnesia|
|R60.0 - R60.9||Edema, not elsewhere classified|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood and adults|
|R63.4||Abnormal weight loss|
|R94.4||Abnormal results of kidney function studies|
|T37.8X1+ - T37.8X4+||Poisoning by, adverse effect of and underdosing of other specified systemic anti-infectives and antiparasitics|
|T39.4x1+ - T39.4x4+||Poisoning by, adverse effect of and underdosing of antirheumatics, not elsewhere classified [gold salts]|
|T45.4X1+ - T45.4X4+||Poisoning by, adverse effect of and underdosing of iron and its compounds|
|T49.4X1+ - T49.4X4+||Poisoning by, adverse effect of and underdosing of keratolytics, keratoplastics, and other hair treatment drugs and preparations|
|T56.0x1+ - T56.94x+||Toxic effect of metals|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T56.1X1+ - T56.1X4+||Toxic effect of mercury and its compounds|
|T56.3X1+ - T56.3X4+||Toxic effect of cadmium and its compounds|
|T56.4X1+ - T56.6X4+||Toxic effects of copper, zinc, tin and its compounds|
|T56.811+ - T56.894+||Toxic effects of thallium and other metals|
|T57.0x1+ - T57.0x4+||Toxic effect of arsenic and its compounds|
|T74.01X+||Adult neglect or abandonment, confirmed|
|T74.02X+||Child neglect or abandonment, confirmed|
|T76.01X+||Adult neglect or abandonment, suspected|
|T76.02X+||Child neglect or abandonment, suspected|
|T74.92X+||Unspecified child maltreatment, confirmed|
|T76.92X+||Unspecified child maltreatment, suspected|
|Z77.011||Contact with and (suspected) exposure to lead|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|R53.83||Other fatigue [lethargy]|
|Dimercaptosuccinic acid (DMSA) or ethylenediaminetetraacetic (EDTA) provocative chelation/mobilization test:|
|NO specific code|
|ICD-10 codes not covered for indications listed in the CPB:|
|T56.0x1+ - T56.0x4+||Toxic effects of lead and its compounds| |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0360 | Each additional hr 1-8 hrs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0362 | Each add sequential infusion | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0359 | Chemotherapy IV one hr initi | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0267 | Bone marrow or psc harvest | CPT | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0265 | Cryopresevation Freeze+stora | CPT | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
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