code
stringlengths 4
12
| description
stringlengths 2
264
| codetype
stringclasses 8
values | context
stringlengths 160
15.5k
|
|---|---|---|---|
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. |
G0361 | Prolong chemo infuse>8hrs pu | 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. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0360 | Each additional hr 1-8 hrs | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0362 | Each add sequential infusion | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0359 | Chemotherapy IV one hr initi | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | 3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.20 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. ICD-9 codes 200.00-200.28 and 200.80-200.88 added
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/11/2008: Policy description and statements updated. Peripheral T-cell lymphoma added as investigational for either autologous or allogeneic stem-cell support. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. |
G0267 | Bone marrow or psc harvest | CPT | Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. |
G0265 | Cryopresevation Freeze+stora | CPT | Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. |
G0266 | Thawing + expansion froz cel | CPT | Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. |
86825 | X-MATCHAHG | HCPCS | Policy statement updated to include medically necessary indications for allogeneic SCT and/or autologous SCT and medically necessary indications for reduced intensity conditioning allogeneic SCT. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. |
86826 | Hla x-match noncytotoxc addl | HCPCS | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. |
G0267 | Bone marrow or psc harvest | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. |
G0265 | Cryopresevation Freeze+stora | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. |
G0266 | Thawing + expansion froz cel | CPT | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. |
86825 | X-MATCHAHG | HCPCS | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. |
G0267 | Bone marrow or psc harvest | CPT | Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. |
G0265 | Cryopresevation Freeze+stora | CPT | Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. |
G0266 | Thawing + expansion froz cel | CPT | Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. |
86825 | X-MATCHAHG | HCPCS | Added new CPT Codes 86825 and 86826 to Covered Codes Table. HCPCS Codes G0265, G0266 and G0267 were removed from covered table due to these codes were deleted as of 12-31-2007. 04/20/2011: Policy description updated regarding disease classification, prevalence, and treatment approaches. Policy statement revised to break out mantle cell lymphoma; investigational statements added for autologous as salvage therapy and allogeneic to consolidate a first remission and medically necessary statement added for allogeneic as salvage therapy. Also revised the policy statement to break out peripheral T-cell lymphoma; added statements as medically necessary for autologous to consolidate first remission in specific situations and autologous and allogeneic as salvage therapy, and as investigational regarding allogeneic HSCT to consolidate a first complete remission. |
38241 | Transplt autol hct/donor | HCPCS | In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. |
38240 | Transplt allo hct/donor | HCPCS | In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. |
96445 | Chemotherapy, intracavitary | HCPCS | In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | In first medically necessary statement for patients with mature T-cell or NK-cell (peripheral T-cell) neoplasms, "high-risk peripheral T-cell lymphoma" changed to "high-risk subtypes." Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. |
30230Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30240Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30230G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30230Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30233Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
96445 | Chemotherapy, intracavitary | HCPCS | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30243G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
38241 | Transplt autol hct/donor | HCPCS | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30230G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
38240 | Transplt allo hct/donor | HCPCS | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30240G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30243Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30243G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30243Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30240Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30233G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30240G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30233G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30233Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy guidelines updated to add information regarding salvage therapy and high-risk (aggressive) T-cell and natural killer cell neoplasms. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. |
30233G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 05/25/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30230Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30243G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30233Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
30240Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Policy Guidelines updated to add medically necessary and investigative definitions. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. Blue Cross Blue Shield Association Policy # 8.01.20
This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.