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63621 | Srs spinal lesion addl | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61795 | Brain surgery using computer | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
G0243 | MX-SRC PHOTON STERO RADIOSURG DEL W/COLLMTR CHGS | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77373 | Sbrt delivery | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77299 | HC UNLIS PX THER RADIOL CLINICAL TX PLANNING | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77416 | Radiation treatment delivery | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77523 | Proton trmt intermediate | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61781 | Scan proc cranial intra | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
63620 | Srs spinal lesion | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77399 | HC UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61793 | Focus Radiation Beam | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61783 | Scan proc spinal | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77520 | Proton trmt simple w/o comp | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61799 | Srs cran les complex addl | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77525 | Proton treatment complex | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
S8030 | Tantalum ring application | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
G6011 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6007 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6012 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6003 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6005 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6009 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6013 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6008 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77412 | RAD TRMT DELIVERY, > 1 MEV, COMPL | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6010 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6014 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6004 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
61795 | Brain surgery using computer | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6006 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6011 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6007 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6012 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6003 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6005 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6009 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6013 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6008 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
77412 | RAD TRMT DELIVERY, > 1 MEV, COMPL | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6010 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6014 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6004 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
61795 | Brain surgery using computer | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6006 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6011 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6007 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6012 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6003 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6005 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6009 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6013 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6008 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
77412 | RAD TRMT DELIVERY, > 1 MEV, COMPL | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6010 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6014 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6004 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6006 | Radiation treatment delivery | HCPCS | 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy. |
G6011 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6007 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6012 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6003 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6005 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6009 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6013 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6008 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
77412 | RAD TRMT DELIVERY, > 1 MEV, COMPL | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6010 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6014 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6004 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6006 | Radiation treatment delivery | HCPCS | 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. |
G6011 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6007 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6012 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6003 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6005 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6009 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6013 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6008 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6010 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6014 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6004 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
G6006 | Radiation treatment delivery | HCPCS | Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This 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. Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
The codes used for treatment delivery will depend on the energy source used. |
L8606 | SYRINGE DURASPHERE EXP 1ML | HCPCS | Added bulking agent HCPCS codes L8603, L8604, and L8606. 12/30/2010: Policy reviewed; no changes. 12/01/2011: Policy reviewed; no changes. 12/13/2013: Policy reviewed; no changes to policy statement. Deleted duplicated ureter as a contraindication in the policy guidelines. |
L8604 | SYRINGE DEFLUX INJ PREFILL 1ML GLASS | HCPCS | Added bulking agent HCPCS codes L8603, L8604, and L8606. 12/30/2010: Policy reviewed; no changes. 12/01/2011: Policy reviewed; no changes. 12/13/2013: Policy reviewed; no changes to policy statement. Deleted duplicated ureter as a contraindication in the policy guidelines. |
L8603 | Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies | HCPCS | Added bulking agent HCPCS codes L8603, L8604, and L8606. 12/30/2010: Policy reviewed; no changes. 12/01/2011: Policy reviewed; no changes. 12/13/2013: Policy reviewed; no changes to policy statement. Deleted duplicated ureter as a contraindication in the policy guidelines. |
85048 | WHITE CELL COUNT (WBC) | HCPCS | Nasal NO production appeared to decrease with age and also seemed to be associated to overall olfactory function and in particular to central nervous system tasks such as olfactory discrimination and identification but not to olfactory thresholds. The authors stated that these findings raised questions about the link and interaction between olfactory function and nNO. |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 "+":|
|CPT codes covered if selection criteria are met:|
|31231||Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)|
|70450||Computed tomography head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|82947||Glucose; quantitative, blood (except reagent strip)|
|84443||Thyroid stimulating hormone (TSH)|
|84520||Urea nitrogen; quantitative|
|85014||Blood count; hematocrit (Hct)|
|85032||manual cell count (erythrocyte, leukocyte, or platelet) each|
|85048||leukocyte (WBC), automated|
|85651 - 85652||Sedimentation rate, erythrocyte|
|86003||Allergen specific IgE; quantitative or semiquantitative, each allergen|
|CPT codes not covered for indications listed in the CPB:|
|78267||Urea breath test, C-14 (isotopic); acquisition for analysis [Helicobacter pylori]|
|78268||analysis [Helicobacter pylori]|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|83013||Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)|
|87338||Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool|
|92512||Nasal function studies (e.g., rhinomanometry)|
|95012||Nitric oxide expired gas determination|
|Other CPT codes related to the CPB:|
|31233||Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)|
|31235||Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoid face or cannulation of ostium)|
|31237||Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or debridement (separate procedure)|
|80150 - 80202||Therapeutic drug assays|
|92511||Nasopharyngoscopy with endoscope (separate procedure)|
|95816 - 95819||Electroencephalogram (EEG) including recording awake and drowsy or including awake and asleep|
|ICD-10 codes covered if selection criteria are met:|
|R43.0 - R43.9||Disturbances of smell and taste| |
31231 | PR NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX | HCPCS | Nasal NO production appeared to decrease with age and also seemed to be associated to overall olfactory function and in particular to central nervous system tasks such as olfactory discrimination and identification but not to olfactory thresholds. The authors stated that these findings raised questions about the link and interaction between olfactory function and nNO. |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 "+":|
|CPT codes covered if selection criteria are met:|
|31231||Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)|
|70450||Computed tomography head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|82947||Glucose; quantitative, blood (except reagent strip)|
|84443||Thyroid stimulating hormone (TSH)|
|84520||Urea nitrogen; quantitative|
|85014||Blood count; hematocrit (Hct)|
|85032||manual cell count (erythrocyte, leukocyte, or platelet) each|
|85048||leukocyte (WBC), automated|
|85651 - 85652||Sedimentation rate, erythrocyte|
|86003||Allergen specific IgE; quantitative or semiquantitative, each allergen|
|CPT codes not covered for indications listed in the CPB:|
|78267||Urea breath test, C-14 (isotopic); acquisition for analysis [Helicobacter pylori]|
|78268||analysis [Helicobacter pylori]|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|83013||Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)|
|87338||Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool|
|92512||Nasal function studies (e.g., rhinomanometry)|
|95012||Nitric oxide expired gas determination|
|Other CPT codes related to the CPB:|
|31233||Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)|
|31235||Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoid face or cannulation of ostium)|
|31237||Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or debridement (separate procedure)|
|80150 - 80202||Therapeutic drug assays|
|92511||Nasopharyngoscopy with endoscope (separate procedure)|
|95816 - 95819||Electroencephalogram (EEG) including recording awake and drowsy or including awake and asleep|
|ICD-10 codes covered if selection criteria are met:|
|R43.0 - R43.9||Disturbances of smell and taste| |
82947 | HC GLUCOSE; QUANTITATIVE, WHOLE BLOOD | HCPCS | Nasal NO production appeared to decrease with age and also seemed to be associated to overall olfactory function and in particular to central nervous system tasks such as olfactory discrimination and identification but not to olfactory thresholds. The authors stated that these findings raised questions about the link and interaction between olfactory function and nNO. |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 "+":|
|CPT codes covered if selection criteria are met:|
|31231||Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)|
|70450||Computed tomography head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|82947||Glucose; quantitative, blood (except reagent strip)|
|84443||Thyroid stimulating hormone (TSH)|
|84520||Urea nitrogen; quantitative|
|85014||Blood count; hematocrit (Hct)|
|85032||manual cell count (erythrocyte, leukocyte, or platelet) each|
|85048||leukocyte (WBC), automated|
|85651 - 85652||Sedimentation rate, erythrocyte|
|86003||Allergen specific IgE; quantitative or semiquantitative, each allergen|
|CPT codes not covered for indications listed in the CPB:|
|78267||Urea breath test, C-14 (isotopic); acquisition for analysis [Helicobacter pylori]|
|78268||analysis [Helicobacter pylori]|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|83013||Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)|
|87338||Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool|
|92512||Nasal function studies (e.g., rhinomanometry)|
|95012||Nitric oxide expired gas determination|
|Other CPT codes related to the CPB:|
|31233||Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)|
|31235||Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoid face or cannulation of ostium)|
|31237||Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or debridement (separate procedure)|
|80150 - 80202||Therapeutic drug assays|
|92511||Nasopharyngoscopy with endoscope (separate procedure)|
|95816 - 95819||Electroencephalogram (EEG) including recording awake and drowsy or including awake and asleep|
|ICD-10 codes covered if selection criteria are met:|
|R43.0 - R43.9||Disturbances of smell and taste| |
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