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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 HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." Removed "squamous cell" from the first medically necessary policy statement. |
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 HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." Removed "squamous cell" from the first medically necessary policy statement. |
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 HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." Removed "squamous cell" from the first medically necessary policy statement. |
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 HCPCS codes to the Code Reference section: G6015, G6016. 01/27/2015: Policy description updated regarding radiation techniques. Policy statements updated to change "radiation therapy" to "radiotherapy." Removed "squamous cell" from the first medically necessary policy statement. |
G6015 | Radiation tx delivery imrt | HCPCS | Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77386 | HC IMRT COMPLEX | HCPCS | Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77385 | HC IMRT SIMPLE | HCPCS | Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6015 | Radiation tx delivery imrt | HCPCS | Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77386 | HC IMRT COMPLEX | HCPCS | Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77385 | HC IMRT SIMPLE | HCPCS | Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Policy guidelines updated regarding localized prostate cancer. 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions. |
E0673 | Segmental gradient pressure pneumatic appliance, half leg | HCPCS | Therefore, when a claim for a segmented pneumatic compression device that allows for manual control in each chamber is received, payment must be made for the least expensive medically appropriate device. If a patient medically needs a segmented device but does not need manual controls, payment must be made for E0651. The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. |
E0651 | Pneum compressor segmental | HCPCS | Therefore, when a claim for a segmented pneumatic compression device that allows for manual control in each chamber is received, payment must be made for the least expensive medically appropriate device. If a patient medically needs a segmented device but does not need manual controls, payment must be made for E0651. The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. |
E0655 | Pneumatic appliance half arm | HCPCS | Therefore, when a claim for a segmented pneumatic compression device that allows for manual control in each chamber is received, payment must be made for the least expensive medically appropriate device. If a patient medically needs a segmented device but does not need manual controls, payment must be made for E0651. The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. |
E0650 | Pneumatic compressor, non-segmental home model | HCPCS | Therefore, when a claim for a segmented pneumatic compression device that allows for manual control in each chamber is received, payment must be made for the least expensive medically appropriate device. If a patient medically needs a segmented device but does not need manual controls, payment must be made for E0651. The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. |
E0652 | Pneum compres w/cal pressure | HCPCS | Therefore, when a claim for a segmented pneumatic compression device that allows for manual control in each chamber is received, payment must be made for the least expensive medically appropriate device. If a patient medically needs a segmented device but does not need manual controls, payment must be made for E0651. The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. |
E0673 | Segmental gradient pressure pneumatic appliance, half leg | HCPCS | The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. |
E0651 | Pneum compressor segmental | HCPCS | The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. |
E0655 | Pneumatic appliance half arm | HCPCS | The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. |
E0650 | Pneumatic compressor, non-segmental home model | HCPCS | The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. |
E0652 | Pneum compres w/cal pressure | HCPCS | The segmented device with manual control (E0652) is covered only when there are unique characteristics that prevent the individual from receiving satisfactory pneumatic treatment using a less costly device; e.g., significant sensitive skin scars or the presence of contracture or pain caused by a clinical condition that requires the more costly manual control device." The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. |
E0673 | Segmental gradient pressure pneumatic appliance, half leg | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. Links added to related medical policies. |
E0651 | Pneum compressor segmental | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. Links added to related medical policies. |
E0655 | Pneumatic appliance half arm | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. Links added to related medical policies. |
E0650 | Pneumatic compressor, non-segmental home model | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. Links added to related medical policies. |
E0652 | Pneum compres w/cal pressure | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY12/1992: Approved by Medical Policy Advisory Committee (MPAC) as "Segmental Lymphedema Pump"
8/1997: Revision approved by MPAC; policy renamed
2/19/2002: Managed Care Requirements deleted
5/1/2002: Type of Service and Place of Service deleted
8/19/2002: HCPCS code E0652 description added
9/20/2002: Policy reviewed, Sources updated
8/21/2003: HCPCS E0650-E0651, E0655-E0673 listed separately
10/17/2005: ICD-9 Diagnosis 990 deleted
7/13/2006: Policy updated
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. 11/20/2008: Policy reviewed by MPAC, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/12/2010: Policy title changed from "Lymphedema Pumps" to "Pneumatic Compression Pumps for Treatment of Lymphedema." Policy description revised to add information regarding available pumps. Links added to related medical policies. |
1745 | Thoracoscopic robotic assisted procedure | ICD | doi:10.1016/j.biopsych.2006.08.041. PMID 17141745. - World Health Organisation (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation. |
1745 | Thoracoscopic robotic assisted procedure | ICD | PMID 17141745. - World Health Organisation (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation. ISBN 978-92-4-154422-1. |
G6015 | Radiation tx delivery imrt | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77386 | HC IMRT COMPLEX | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
77385 | HC IMRT SIMPLE | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Policy description and statement updated to change "radiation therapy" to "radiotherapy" throughout policy. Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. |
G6015 | Radiation tx delivery imrt | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77386 | HC IMRT COMPLEX | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
77385 | HC IMRT SIMPLE | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added policy statement: IMRT is not medically necessary for the treatment of breast or lung cancer 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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
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. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. |
G6015 | Radiation tx delivery imrt | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines updated to add medically necessary and investigative definitions. |
G6016 | PR DELIVERY COMP IMRT | HCPCS | Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines updated to add medically necessary and investigative definitions. |
87797 | HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. |
87799 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. |
87798 | VARICELLA ZOSTER PCR | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. |
87797 | HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. |
87799 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. |
87798 | VARICELLA ZOSTER PCR | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. |
87798 | VARICELLA ZOSTER PCR | HCPCS | POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table. |
87641 | STAPH AUREUS NASAL PCR | HCPCS | POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table. |
87799 | INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM | HCPCS | POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table. |
87640 | STAPH A DNA AMP PROBE | HCPCS | POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table. |
87797 | HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF | HCPCS | POLICY HISTORY10/26/2006: Policy added
1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table. |
A9505 | TL201 THALLOUS CL DX MCI Injectable Drugs Not on Fee Schedule | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A4642 | RRX INDIUM 111 SATUMOMAB DX 0 6MCI | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
S8080 | SCINTIMAMMO UNI W/SPL RADIOPHARM | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A4641 | RADIOPHARM DX NOC Injectable Drugs Not on Fee Schedule | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A9505 | TL201 THALLOUS CL DX MCI Injectable Drugs Not on Fee Schedule | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A4642 | RRX INDIUM 111 SATUMOMAB DX 0 6MCI | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9549 | Tc99m arcitumomab | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9565 | In111 pentetreotide | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
S8080 | SCINTIMAMMO UNI W/SPL RADIOPHARM | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A4641 | RADIOPHARM DX NOC Injectable Drugs Not on Fee Schedule | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
99499 | HC CONSULTATIVE PHYSICIAN, PRIMARY PHYSICIAN, PSYCHOLOGISTS, NP | HCPCS | In this
situation, you would add a/an
Level II code. When a neonate or infant is not considered critically ill but still needs intensive observation and other
intensive care services, the initial and continuing intensive care services codes are
99499, unlisted evaluation and management services. What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level
What type of code includes all the words that describe the procedure the code represents? The _______ is the universal health insurance form for submission of outpatient services. J codes in the HCPCS Level II system are used to indicate
medications and dosages. |
L5857 | Elec knee-shin swing only | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5858 | Stance phase only | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5856 | Elec knee-shin swing/stance | HCPCS | Non-covered codes table removed. Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. |
L5857 | Elec knee-shin swing only | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
L5858 | Stance phase only | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
L5856 | Elec knee-shin swing/stance | HCPCS | Covered codes table added. HCPCS L5856, L5857, and L5858 moved to covered. ICD-9 codes 897.2-897.7 and V43.65 added
11/15/2007: Revised policy approved by MPAC
4/27/2010: Title changed from "Prosthetic Knees" to "Prostheses for the Lower Limb." Description section revised to include ankle-foot prostheses information. Policy statement section was revised to add two new policy statements regarding ankle-foot and powered knee prostheses; these are considered investigational. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0362 | Each add sequential infusion | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The majority of patients will have such a donor; however, the risk of GVHD and overall morbidity of the procedure may be severe, and experience with these donors is not as extensive as that with matched donors. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
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