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G0357 | IV PUSH TECHNIQUE SINGLE/INIT 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. |
G0356 | HORMONAL ANTINEOPLASTIC | 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. |
G0266 | Thawing + expansion froz cel | 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. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | 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. |
S2142 | Cord blood-derived stem-cell 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. |
86826 | Hla x-match noncytotoxc addl | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | 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. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G6015 | Radiation tx delivery imrt | HCPCS | Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. |
77386 | HC IMRT COMPLEX | HCPCS | Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. |
77385 | HC IMRT SIMPLE | HCPCS | Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. |
77386 | HC IMRT COMPLEX | HCPCS | Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. |
77385 | HC IMRT SIMPLE | HCPCS | Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. |
G6015 | Radiation tx delivery imrt | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
77386 | HC IMRT COMPLEX | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
77385 | HC IMRT SIMPLE | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
1745 | Thoracoscopic robotic assisted procedure | ICD | The Monmouth and Ocean County breast cancer death rate in the past two decades was 20.1% above the U.S., but 4.5% below for all causes other than cancer (Table 5). These differences are consistent for young, middle-aged, and older women. Mortality, Monmouth/Ocean Counties vs. U.S.
From Cancer and From All Other Causes, 1985-2003
|All Cancers||Cancer||% Local is +/- U.S.|
|Age 0-14||133||+13.4||– 31.7|
|Age 15-44||1745||+12.0||– 16.4|
|All- Whites||51430||+10.7||– 3.8|
|All- Blacks||2478||+ 5.3||+ 0.4|
|Breast Cancer (white females)|
|Age 25-44||263||+19.6||– 12.9|
|Age 45-64||1223||+18.9||– 5.0|
|Age 65+||3000||+21.7||– 3.2|
|All Ages||4486||+20.1||– 4.5|
|Source: U.S. Centers for Disease Control and Prevention, http://wonder.cdc.gov, underlying cause of death. Uses ICD-9 cancer codes 140.0-208.9 (1994-1998) and ICD-10 cancer codes C00-C97.9 (1999-2003). Uses ICD-9 breast cancer codes 174.0-174.9 (1994-1998) and ICD-10 cancer codes C50-C50.9 (1999-2003). |
1745 | Thoracoscopic robotic assisted procedure | ICD | These differences are consistent for young, middle-aged, and older women. Mortality, Monmouth/Ocean Counties vs. U.S.
From Cancer and From All Other Causes, 1985-2003
|All Cancers||Cancer||% Local is +/- U.S.|
|Age 0-14||133||+13.4||– 31.7|
|Age 15-44||1745||+12.0||– 16.4|
|All- Whites||51430||+10.7||– 3.8|
|All- Blacks||2478||+ 5.3||+ 0.4|
|Breast Cancer (white females)|
|Age 25-44||263||+19.6||– 12.9|
|Age 45-64||1223||+18.9||– 5.0|
|Age 65+||3000||+21.7||– 3.2|
|All Ages||4486||+20.1||– 4.5|
|Source: U.S. Centers for Disease Control and Prevention, http://wonder.cdc.gov, underlying cause of death. Uses ICD-9 cancer codes 140.0-208.9 (1994-1998) and ICD-10 cancer codes C00-C97.9 (1999-2003). Uses ICD-9 breast cancer codes 174.0-174.9 (1994-1998) and ICD-10 cancer codes C50-C50.9 (1999-2003). All age data adjusted to 2000 U.S. standard population. |
1745 | Thoracoscopic robotic assisted procedure | ICD | Mortality, Monmouth/Ocean Counties vs. U.S.
From Cancer and From All Other Causes, 1985-2003
|All Cancers||Cancer||% Local is +/- U.S.|
|Age 0-14||133||+13.4||– 31.7|
|Age 15-44||1745||+12.0||– 16.4|
|All- Whites||51430||+10.7||– 3.8|
|All- Blacks||2478||+ 5.3||+ 0.4|
|Breast Cancer (white females)|
|Age 25-44||263||+19.6||– 12.9|
|Age 45-64||1223||+18.9||– 5.0|
|Age 65+||3000||+21.7||– 3.2|
|All Ages||4486||+20.1||– 4.5|
|Source: U.S. Centers for Disease Control and Prevention, http://wonder.cdc.gov, underlying cause of death. Uses ICD-9 cancer codes 140.0-208.9 (1994-1998) and ICD-10 cancer codes C00-C97.9 (1999-2003). Uses ICD-9 breast cancer codes 174.0-174.9 (1994-1998) and ICD-10 cancer codes C50-C50.9 (1999-2003). All age data adjusted to 2000 U.S. standard population. All differences statistically significant at p<.05 except for all cancers for blacks.|
The five most common causes of death (circulatory disease, cancer, respiratory disease, accidents/suicide/homicide, and nervous system diseases) account for about 83% of all death nationally. |
S9345 | HIT anti-hemophil diem | HCPCS | The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. |
36440 | PR PUSH TRANSFUSION BLOOD 2 YR OR YOUNGER | HCPCS | The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. |
85244 | HC CLOTTING; FACTOR VIII (AHG) RELATED ANTIGEN | HCPCS | The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. |
1999 | ANESTHESIOLOGY GROUP | CPT | The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. |
S9345 | HIT anti-hemophil diem | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. |
36440 | PR PUSH TRANSFUSION BLOOD 2 YR OR YOUNGER | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. |
85244 | HC CLOTTING; FACTOR VIII (AHG) RELATED ANTIGEN | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee
1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one policy titled "Factor VIII"; Prior authorization deleted
4/24/2002: Type of Service and Place of Service deleted. Code Reference section completed
11/6/2002: Koate-DVI® added, Koate-P® and Koate-HP® deleted
8/17/2004: Code Reference section updated, ICD-9 diagnosis code 286.1, 286.4, 286.5 added, HCPCS S9345 added
9/24/2004: Code Reference section updated, CPT code 36440, 85244 deleted
10/29/2006: Factor VIII and Factor IX policies combined
9/12/2007: Added Mississippi Comprehensive Health Insurance Risk Pool Association will no longer provide benefits for antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or related supplies received on an outpatient basis effective August 1, 2007, to Policy Exceptions
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions. 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. |
Q2023 | Xyntha - inj | CPT | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint damage in children (0-16) with hemophilia A with no pre-existing joint damage. 12/15/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
03/08/2010: Description section was updated with Humate-P®, Wilate®. |
Q2023 | Xyntha - inj | CPT | BCBSMS information added. 6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint damage in children (0-16) with hemophilia A with no pre-existing joint damage. 12/15/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
03/08/2010: Description section was updated with Humate-P®, Wilate®. Also added brand names (ReFacto®, Xyntha® and Advate®) for Factor VIII (recombinant). |
Q2023 | Xyntha - inj | CPT | 6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint damage in children (0-16) with hemophilia A with no pre-existing joint damage. 12/15/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
03/08/2010: Description section was updated with Humate-P®, Wilate®. Also added brand names (ReFacto®, Xyntha® and Advate®) for Factor VIII (recombinant). Policy Section updated with coverage for Von Willebrand disease for Factor VIII. |
J7185 | Xyntha inj | HCPCS | Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." |
J7184 | Wilate injection | HCPCS | Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." |
J7185 | Xyntha inj | HCPCS | Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. |
J7184 | Wilate injection | HCPCS | Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. |
J7185 | Xyntha inj | HCPCS | HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. |
J7187 | Injection, von willebrand factor complex (humate-p), per iu vwf:rco | HCPCS | HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. |
J7184 | Wilate injection | HCPCS | HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Factor IX." Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. |
J7182 | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | HCPCS | Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. |
J7200 | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | HCPCS | Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. |
J7201 | Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. | HCPCS | Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. |
J7182 | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | HCPCS | Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. |
J7200 | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | HCPCS | Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. |
J7201 | Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. | HCPCS | Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. |
J7182 | Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu | HCPCS | 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. |
J7200 | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | HCPCS | 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. |
J7201 | Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. | HCPCS | 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. |
J7200 | Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu | HCPCS | Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. |
J7201 | Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u. | HCPCS | Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. |
J7184 | Wilate injection | HCPCS | Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. |
J7195 | Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified | HCPCS | Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. |
J7184 | Wilate injection | HCPCS | 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: Policy description updated to add the brand name Nuwiq® for Factor VIII (recombinant) and brand names Rixibus® and Ixinity® for Factor IX (recombinant). |
J7184 | Wilate injection | HCPCS | 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: Policy description updated to add the brand name Nuwiq® for Factor VIII (recombinant) and brand names Rixibus® and Ixinity® for Factor IX (recombinant). Policy statement unchanged. |
J7184 | Wilate injection | HCPCS | Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: Policy description updated to add the brand name Nuwiq® for Factor VIII (recombinant) and brand names Rixibus® and Ixinity® for Factor IX (recombinant). Policy statement unchanged. Policy guidelines updated to add medically necessary definition. |
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-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-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| |
31254 | PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31294 | PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
61548 | Removal of pituitary gland | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31288 | PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
G0340 | Robt lin-radsurg fractx 2-5 | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31287 | PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
G0339 | Robot lin-radsurg com, first | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31276 | PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
S8030 | Tantalum ring application | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31290 | PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31256 | PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
31267 | PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. |
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