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E0691 | Uvl pnl 2 sq ft or less | 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. |
A4633 | Uvl replacement bulb | 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. |
E0690 | UV CABINET APPROPRIATE HOME USE | 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. |
E0693 | Uvl sys panel 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. |
92135 | Ophth dx imaging post seg | 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 HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC)
4/12/2001: Managed Care Requirements deleted
5/2001: Reviewed by MPAC; investigational status remains
2/7/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section completed
11/2002: Reviewed by MPAC; Scanning Laser Polarimetry (SLP) changed to medically necessary
7/2003: Reviewed by MPAC; "Description" section revised to be consistent with BCBSA, scanning laser ophthalmoscopy and optical coherence tomography are medically necessary for high risk individuals, scanning laser ophthalmoscopy, optical coherence tomography and scanning laser polarimetry are considered investigational as a method of monitoring disease progression in patients with glaucoma and as a screening test for glaucoma in the general population, measurement of pulsatile ocular blood flow or blood flow velocity with doppler ultrasonography is considered investigational in the diagnosis and follow-up of patients with glaucoma, FEP exception added
11/1/2004: Code Reference section updated, CPT code 92135 moved to covered, ICD-9 procedure code 88.90 added covered codes, ICD-9 diagnosis code 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 360.21, 362.85, V19.0 added covered codes, ICD-9 diagnosis 365.00, 365.01, 365.02, 365.03, 365.04, 365.10, 365.11, 365.12, 365.13, 365.14, 365.15, 365.20, 365.21, 365.22, 365.23, 365.24, 365.31, 365.32, 365.41, 365.42, 365.43, 365.44, 365.51, 365.52, 365.59, 365.60, 365.61, 365.62, 365.63, 365.64, 365.65, 365.81, 365.82, 365.83, 365.89, 365.9 description revised and moved from non-covered to covered, CPT code 93875 added to non-covered codes
1/10/2005: Code Reference section updated, ICD-9 diagnosis code 362.01, 362.02, 368.40, 368.41, 368.42, 368.43, 368.44, 368.45, 368.46, 368.47 added covered codes, HCPCS S0820 deleted
11/16/2005: Code Reference section updated, ICD9 diagnosis codes 362.03 - 362.07 added
3/17/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/18/2008: Policy reviewed, no changes
9/16/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/03/2010: Policy Description revised to remove optic nerve head analyzers. Policy statement revised to remove optic nerve head analyzers and analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography. FEP verbiage revised in Policy Exceptions section. |
93875 | Extracranial study | 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 HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC)
4/12/2001: Managed Care Requirements deleted
5/2001: Reviewed by MPAC; investigational status remains
2/7/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section completed
11/2002: Reviewed by MPAC; Scanning Laser Polarimetry (SLP) changed to medically necessary
7/2003: Reviewed by MPAC; "Description" section revised to be consistent with BCBSA, scanning laser ophthalmoscopy and optical coherence tomography are medically necessary for high risk individuals, scanning laser ophthalmoscopy, optical coherence tomography and scanning laser polarimetry are considered investigational as a method of monitoring disease progression in patients with glaucoma and as a screening test for glaucoma in the general population, measurement of pulsatile ocular blood flow or blood flow velocity with doppler ultrasonography is considered investigational in the diagnosis and follow-up of patients with glaucoma, FEP exception added
11/1/2004: Code Reference section updated, CPT code 92135 moved to covered, ICD-9 procedure code 88.90 added covered codes, ICD-9 diagnosis code 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 360.21, 362.85, V19.0 added covered codes, ICD-9 diagnosis 365.00, 365.01, 365.02, 365.03, 365.04, 365.10, 365.11, 365.12, 365.13, 365.14, 365.15, 365.20, 365.21, 365.22, 365.23, 365.24, 365.31, 365.32, 365.41, 365.42, 365.43, 365.44, 365.51, 365.52, 365.59, 365.60, 365.61, 365.62, 365.63, 365.64, 365.65, 365.81, 365.82, 365.83, 365.89, 365.9 description revised and moved from non-covered to covered, CPT code 93875 added to non-covered codes
1/10/2005: Code Reference section updated, ICD-9 diagnosis code 362.01, 362.02, 368.40, 368.41, 368.42, 368.43, 368.44, 368.45, 368.46, 368.47 added covered codes, HCPCS S0820 deleted
11/16/2005: Code Reference section updated, ICD9 diagnosis codes 362.03 - 362.07 added
3/17/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/18/2008: Policy reviewed, no changes
9/16/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/03/2010: Policy Description revised to remove optic nerve head analyzers. Policy statement revised to remove optic nerve head analyzers and analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography. FEP verbiage revised in Policy Exceptions section. |
S0820 | COMPUTERIZED CORNEAL TOPOGRA | 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 HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC)
4/12/2001: Managed Care Requirements deleted
5/2001: Reviewed by MPAC; investigational status remains
2/7/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section completed
11/2002: Reviewed by MPAC; Scanning Laser Polarimetry (SLP) changed to medically necessary
7/2003: Reviewed by MPAC; "Description" section revised to be consistent with BCBSA, scanning laser ophthalmoscopy and optical coherence tomography are medically necessary for high risk individuals, scanning laser ophthalmoscopy, optical coherence tomography and scanning laser polarimetry are considered investigational as a method of monitoring disease progression in patients with glaucoma and as a screening test for glaucoma in the general population, measurement of pulsatile ocular blood flow or blood flow velocity with doppler ultrasonography is considered investigational in the diagnosis and follow-up of patients with glaucoma, FEP exception added
11/1/2004: Code Reference section updated, CPT code 92135 moved to covered, ICD-9 procedure code 88.90 added covered codes, ICD-9 diagnosis code 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 360.21, 362.85, V19.0 added covered codes, ICD-9 diagnosis 365.00, 365.01, 365.02, 365.03, 365.04, 365.10, 365.11, 365.12, 365.13, 365.14, 365.15, 365.20, 365.21, 365.22, 365.23, 365.24, 365.31, 365.32, 365.41, 365.42, 365.43, 365.44, 365.51, 365.52, 365.59, 365.60, 365.61, 365.62, 365.63, 365.64, 365.65, 365.81, 365.82, 365.83, 365.89, 365.9 description revised and moved from non-covered to covered, CPT code 93875 added to non-covered codes
1/10/2005: Code Reference section updated, ICD-9 diagnosis code 362.01, 362.02, 368.40, 368.41, 368.42, 368.43, 368.44, 368.45, 368.46, 368.47 added covered codes, HCPCS S0820 deleted
11/16/2005: Code Reference section updated, ICD9 diagnosis codes 362.03 - 362.07 added
3/17/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/18/2008: Policy reviewed, no changes
9/16/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
08/03/2010: Policy Description revised to remove optic nerve head analyzers. Policy statement revised to remove optic nerve head analyzers and analysis of the optic nerve (retinal nerve fiber layer) in the diagnosis and evaluation of patients with glaucoma or glaucoma suspects may be considered medically necessary when using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography. FEP verbiage revised in Policy Exceptions section. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | The ICD-10 codes are applicable for hospital inpatient procedures. ICD-10-PCS (Procedure Coding System), designed by 3M Health Information Management for Centers of Medicare and Medicaid, is the code set to replace the Volume 3 of ICD-9-CM for inpatient procedure reporting. This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | ICD-10-PCS (Procedure Coding System), designed by 3M Health Information Management for Centers of Medicare and Medicaid, is the code set to replace the Volume 3 of ICD-9-CM for inpatient procedure reporting. This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. It also enhances the quality of healthcare offered to patients. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. It also enhances the quality of healthcare offered to patients. The Department of Health & Human Services (HHS) published the final rules for adoption of new HIPAA standards on January 16, 2009. |
2002 | CARDIAC STRUCTURAL & VALVULAR DISORDERS | APR-DRG | Retrospective case-control study. Administrative claims data from 45 academic medical centers. A total of 10,857 patients who developed health care-associated CDI and were discharged between April 1, 2002, and March 31, 2007 (cases); each case patient was matched by hospital, age, quarter and year of hospital discharge, and diagnosis related group to at least one control patient who did not develop health care-associated CDI (19,214 controls). Patients with health care-associated CDI were identified by using a previously validated method combining the International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI with specific CDI drug therapy (oral or intravenous metronidazole, or oral vancomycin). Costs were determined from charges by using standardized cost:charges ratios and were adjusted for age, All Patient Refined-Diagnosis Related Group (APR-DRG) severity of illness level, race, and sex with use of multivariable linear regression. |
2002 | CARDIAC STRUCTURAL & VALVULAR DISORDERS | APR-DRG | A total of 10,857 patients who developed health care-associated CDI and were discharged between April 1, 2002, and March 31, 2007 (cases); each case patient was matched by hospital, age, quarter and year of hospital discharge, and diagnosis related group to at least one control patient who did not develop health care-associated CDI (19,214 controls). Patients with health care-associated CDI were identified by using a previously validated method combining the International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI with specific CDI drug therapy (oral or intravenous metronidazole, or oral vancomycin). Costs were determined from charges by using standardized cost:charges ratios and were adjusted for age, All Patient Refined-Diagnosis Related Group (APR-DRG) severity of illness level, race, and sex with use of multivariable linear regression. The adjusted mean cost for cases was significantly higher than that for controls ($55,769 vs $28,609), and adjusted mean length of stay was twice as long (21.1 vs 10.0 days). The interaction between CDI and APR-DRG severity of illness level was significant; the effect of CDI on costs and length of stay decreased as severity of illness increased. |
2426 | PLATE 1/3 TUB W/COLLAR 5H 61MM | CDM | To evaluate whether this truly includes all source codes indicating gangrene, several terms (e.g. “gangrene”) were used to search the descriptions in the CONCEPT and SOURCE_TO_CONCEPT_MAP tables to identify source codes. An automated search is then used to evaluate whether each gangrene source code appearing in the data indeed directly or indirectly (through ancestry) maps to the concept “Gangrenous disorder.” The result of this evaluation is shown in Figure 15.3, revealing that the ICD-10 code J85.0 (“Gangrene and necrosis of lung”) was only mapped to concept 4324261 (“Pulmonary necrosis”), which is not a descendant of “Gangrenous disorder.”
15.4 ACHILLES in Practice
Here we will demonstrate how to run ACHILLES against a database in the CDM format. We first need to tell R how to connect to the server. ACHILLES uses the DatabaseConnector package, which provides a function called
?createConnectionDetails for the specific settings required for the various database management systems (DBMS). |
15878 | Suction lipectomy upr extrem | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
97033 | SBT PTA IONTOPHORESIS EACH 15 MIN | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
17999 | UNLISTED PROC SKIN SUBQ | HCPCS | changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis." |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | 01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. |
J0585 | PR INJECTION,ONABOTULINUMTOXINA 1 UNITS | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
J0587 | rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial | HCPCS | BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy. |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | Patients then place an ear-cuff in the external ear canal and treat themselves for 3 minutes, 3 times daily. Treatment is continued for as long as patients find themselves in a period of attacks of vertigo. In 1999, the Meniett® device (Medtronic, Minneapolis, MN) received clearance to market through a U.S. Food and Drug Administration (FDA) 510(k) process specifically as a symptomatic treatment of Meniere's disease. Transtympanic micropressure applications as a treatment of Meniere`s disease are considered investigational. HCPCS code E2120, pulse generator system for tympanic treatment of inner ear endolymphatic fluid, describes the Meniett device. |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | In 1999, the Meniett® device (Medtronic, Minneapolis, MN) received clearance to market through a U.S. Food and Drug Administration (FDA) 510(k) process specifically as a symptomatic treatment of Meniere's disease. Transtympanic micropressure applications as a treatment of Meniere`s disease are considered investigational. HCPCS code E2120, pulse generator system for tympanic treatment of inner ear endolymphatic fluid, describes the Meniett device. Use of the Meniett device requires a prior tympanostomy procedure, a novel indication for this common procedure. Plans with specific medical necessity criteria for tympanostomy may thus be able to prospectively identify claims for the Meniett device. |
A4638 | Repl batt pulse gen sys | HCPCS | 2012. Available online at: http://guidance.nice.org.uk/IPG426/Guidance/pdf/English. Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | 2012. Available online at: http://guidance.nice.org.uk/IPG426/Guidance/pdf/English. Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. |
A4638 | Repl batt pulse gen sys | HCPCS | Available online at: http://guidance.nice.org.uk/IPG426/Guidance/pdf/English. Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | Available online at: http://guidance.nice.org.uk/IPG426/Guidance/pdf/English. Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
A4638 | Repl batt pulse gen sys | HCPCS | Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | Last accessed July 2014. |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
A4638 | Repl batt pulse gen sys | HCPCS | |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
E2120 | Pulse gen sys tx endolymp fl | HCPCS | |ICD-9 Diagnosis||Investigational for all diagnoses|
|386.00 – 386.04||Meniere`s disease code range|
|HCPCS||A4638||Replacement battery for patient-owned ear generator, each|
|E2120||Pulse generator system for tympanic treatment of inner ear endolymphatic fluid|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|H81.01-H81.09||Meniere`s disease code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
Meniere`s Disease, Meniett Device
Meniett Device, Meniere`s Disease
|04/29/03||Add policy to Durable Medical Equipment section||New policy|
|12/17/03||Replace policy||;">New HCPCS codes added only; no other review|
|04/16/04||Replace policy||Policy updated with literature review; no new literature, no change in policy statement|
|11/9/04||Replace policy||Policy updated with literature and review of randomized study. Reference added; no change in policy statement|
|08/17/05||Replace policy||Policy updated with literature search; no changes in policy statement|
|04/17/07||Replace policy||Policy updated with literature search; reference numbers 6 and 7 added; no change in policy statement|
|09/11/08||Replace policy||Policy updated with literature search; references 8-11 added; no change in policy statement|
|10/06/09||Replace policy||Policy updated with literature search through July 2009; reference 11 added; policy statement unchanged|
|10/08/10||Replace policy||Policy updated with literature search through July 2010; policy statement unchanged|
|10/04/11||Replace policy||Policy updated with literature search through July 2011; policy statement unchanged|
|10/11/12||Replace policy||Policy updated with literature search through August 2012; references 12 and 14 added; policy statement unchanged|
|10/10/13||Replace policy||Policy updated with literature search through August 26, 2013; policy statement unchanged|
|10/09/14||Replace policy||Policy updated with literature review through August 28, 2014; policy statement unchanged| |
E1340 | Repair for DME - per 15 min | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
A4556 | PT ELECTRODES | 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. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0608 | APNEA MONITOR | 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. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
A4557 | Lead wires, pair | 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. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0619 | Apnea monitor w recorder | 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. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E0618 | Apnea monitor, without recording feature | 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. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. |
E1340 | Repair for DME - per 15 min | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
A4556 | PT ELECTRODES | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0608 | APNEA MONITOR | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
A4557 | Lead wires, pair | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0619 | Apnea monitor w recorder | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0618 | Apnea monitor, without recording feature | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E1340 | Repair for DME - per 15 min | CPT | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
A4556 | PT ELECTRODES | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
1999 | ANESTHESIOLOGY GROUP | CPT | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0608 | APNEA MONITOR | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
A4557 | Lead wires, pair | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0619 | Apnea monitor w recorder | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0618 | Apnea monitor, without recording feature | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
87476 | LYME DISEASE PCR | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87477 | Lyme dis dna quant | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87475 | Lyme dis dna dir probe | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87476 | LYME DISEASE PCR | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87477 | Lyme dis dna quant | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87475 | Lyme dis dna dir probe | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
J0550 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0540 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87476 | LYME DISEASE PCR | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0530 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87477 | Lyme dis dna quant | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87475 | Lyme dis dna dir probe | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0550 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0540 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0530 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. |
J0550 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0540 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0530 | Penicillin g benzathine inj | HCPCS | No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0580 | Penicillin g benzathine inj | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0560 | Penicillin g benzathine inj | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
J0580 | Penicillin g benzathine inj | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0560 | Penicillin g benzathine inj | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0580 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0560 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0580 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0560 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | CPT is used by insurance companies to determine how much physicians will be paid for their services. HCPCS – Healthcare Common Procedure Coding System is a set of health care procedure codes based on the AMA’s CPT system. HCPCS is a medical billing process used by the Centers for Medicare and Medicaid Services (CMS). This coding system was created to standardize the coding of specific items and services proved by health care professionals and billed to Medicare and Medicaid. The HIPAA Act of 1996 made the use of HCPCS coding mandatory for processing insurance claims through Medicare and Medicaid. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS is a medical billing process used by the Centers for Medicare and Medicaid Services (CMS). This coding system was created to standardize the coding of specific items and services proved by health care professionals and billed to Medicare and Medicaid. The HIPAA Act of 1996 made the use of HCPCS coding mandatory for processing insurance claims through Medicare and Medicaid. It includes circumstances and procedures not included in the CPT and is used by hospitals for non-Medicare and Medicaid cases, as well. Benefits of Electronic Health Records (EHR)
There are many benefits to adopting electronic health records. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | This coding system was created to standardize the coding of specific items and services proved by health care professionals and billed to Medicare and Medicaid. The HIPAA Act of 1996 made the use of HCPCS coding mandatory for processing insurance claims through Medicare and Medicaid. It includes circumstances and procedures not included in the CPT and is used by hospitals for non-Medicare and Medicaid cases, as well. Benefits of Electronic Health Records (EHR)
There are many benefits to adopting electronic health records. Electronic health records offer greater collaboration, patient historical tracking, the ability to properly monitor patients, and less errors and duplicate testing. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | CMS is considering phasing out HCPCS. There are 3 levels within HCPCS:
HCPCS Level 1
Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | There are 3 levels within HCPCS:
HCPCS Level 1
Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. Current Procedural Terminology (CPT) is an outpatient medical coding codeset that is copy-written by the American Medical Association. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. Current Procedural Terminology (CPT) is an outpatient medical coding codeset that is copy-written by the American Medical Association. Despite CPT's widespread use, you have to pay high licensing fees to use the CPT codeset. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
G0360 | Each additional hr 1-8 hrs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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 # 8.01.20 per approval by Medical Policy Advisory Committee (MPAC)
7/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, “High-dose chemotherapy with allogeneic stem-cell support is considered investigational to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.” changed to “High-dose chemotherapy with allogeneic stem-cell support may be considered medically necessary to treat NHL that progresses or relapses relatively soon after a prior course of high-dose chemotherapy with autologous stem-cell support.”
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/20/2005: Code Reference section updated, ICD9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/17/2007: Policy reviewed, description updated. Added marginal zone lymphoma with indolent behavior or lymphoma or lymphoplasmacytoid lymphoma medically necessary for patients with NHL subtypes IWF classified as indolent
9/13/2007: Code reference section updated per the annual ICD-9 code updates. |
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