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86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86822 | Lymphocyte culture primed | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0359 | Chemotherapy IV one hr initi | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0362 | Each add sequential infusion | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86821 | Lymphocyte culture mixed | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86822 | Lymphocyte culture primed | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0360 | Each additional hr 1-8 hrs | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86821 | Lymphocyte culture mixed | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86822 | Lymphocyte culture primed | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0359 | Chemotherapy IV one hr initi | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0362 | Each add sequential infusion | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86813 | HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. |
G0267 | Bone marrow or psc harvest | CPT | Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. |
G0265 | Cryopresevation Freeze+stora | CPT | Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. |
G0266 | Thawing + expansion froz cel | CPT | Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. |
86825 | X-MATCHAHG | HCPCS | Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
1999 | ANESTHESIOLOGY GROUP | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0692 | Uvl sys panel 4 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
97028 | Ultraviolet therapy | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
S9098 | Home phototherapy visit | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0202 | Phototherapy light w/ photom | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4634 | Replacement bulb th lightbox | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0691 | Uvl pnl 2 sq ft or less | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4633 | Uvl replacement bulb | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0690 | UV CABINET APPROPRIATE HOME USE | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0693 | Uvl sys panel 6 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0692 | Uvl sys panel 4 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
97028 | Ultraviolet therapy | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
S9098 | Home phototherapy visit | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0202 | Phototherapy light w/ photom | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4634 | Replacement bulb th lightbox | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0691 | Uvl pnl 2 sq ft or less | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4633 | Uvl replacement bulb | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0690 | UV CABINET APPROPRIATE HOME USE | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0693 | Uvl sys panel 6 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0692 | Uvl sys panel 4 ft | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
97028 | Ultraviolet therapy | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
S9098 | Home phototherapy visit | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0202 | Phototherapy light w/ photom | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
A4634 | Replacement bulb th lightbox | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
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