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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. 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86816 | HC HLA TYPING DR/DQ SINGLE AG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0360 | Each additional hr 1-8 hrs | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
96520 | Port pump refill & main | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86821 | Lymphocyte culture mixed | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
Q0083 | Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38215 | PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86822 | Lymphocyte culture primed | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38240 | Transplt allo hct/donor | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
96545 | Cancer chemotherapy | CPT | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0359 | Chemotherapy IV one hr initi | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
Q0085 | Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86817 | HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
96530 | Syst pump refill & main | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38205 | PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0362 | Each add sequential infusion | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
Q0084 | HC CHEMOTHERAPY - IM PHYS | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
38242 | Transplt allo lymphocytes | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | 1/2004: Interim policy, High-dose chemotherapy with autologous stem-cell support considered investigational to treat primary amyloidosis or Waldenstrom's macroglobulinemia
3/25/2004: Reviewed by MPAC, "High-dose chemotherapy with autologous stem-cell support to treat primary systemic amyloidosis" changed to medically necessary, "High-dose chemotherapy with autologous stem-cell support to treat Waldenstrom’s macroglobulinemia" remains investigational
5/5/2004: Code Reference section completed
8/18/2004: Code Reference section updated, CPT 38215 note added covered codes, CPT chemotherapy administration code range added covered codes, CPT 96520, 96530, 96545 added covered codes, ICD-9 procedure code 41.07, 99.25 added covered codes, HCPCS chemotherapy drug range added covered codes, HCPCS Q0083, Q0084, Q0085 added covered codes, HCPCS S2150 note added covered codes, non-covered table added, CPT 38205, 38240, 38242 added non-covered codes, ICD-9 procedure code 41.05, 41.08, 41.91 added non-covered codes
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference sections updated; Covered table: CPT codes 38230 added; ICD-9 procedure 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; Non-Covered table: CPT-4 code 38204, 86812, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
8/31/2006: Policy reviewed, no changes
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/26/2008: Allogeneic SCT added to policy statements as investigational. Policy description updated. "High Dose Chemotherapy" removed from policy title. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0267 | Bone marrow or psc harvest | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0265 | Cryopresevation Freeze+stora | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
G0266 | Thawing + expansion froz cel | CPT | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
86825 | X-MATCHAHG | HCPCS | Policy description was updated regarding conventional and reduced-intensity conditioning. FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. |
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 the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
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 the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
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 the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
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 the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
86825 | X-MATCHAHG | HCPCS | FEP and State and School Employee verbiage added to Policy Exceptions section. Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. |
86826 | Hla x-match noncytotoxc addl | HCPCS | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0267 | Bone marrow or psc harvest | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0265 | Cryopresevation Freeze+stora | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
G0266 | Thawing + expansion froz cel | CPT | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
86825 | X-MATCHAHG | HCPCS | Added new CPT Codes 86825 and 86826 to the Non-covered table. HCPCS G0265, G0266 and G0267 deleted from Covered table due to codes were deleted as of 12-31-2007. ICD-9 diagnosis code 277.3 deleted from covered table due to code was deleted as of 9-30-2006. 05/09/2011: Policy statement revised to state that autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia. Allogeneic hematopoietic stem-cell transplantation remains investigational to treat Waldenstrom macroglobulinemia. |
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. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 medically necessary and investigative definitions. Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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. |
30230Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30240Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30230G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30230Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30233Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
96445 | Chemotherapy, intracavitary | HCPCS | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30243G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
38241 | Transplt autol hct/donor | HCPCS | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30230G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
38240 | Transplt allo hct/donor | HCPCS | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30240G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30243Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30243G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30243Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30240Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30233G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30240G3 | TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30233G2 | TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30233Y2 | TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg | ICD | Sources section updated. 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
This may not be a comprehensive list of procedure codes applicable to this policy. |
30230Y3 | TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU | ICD | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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. |
96445 | Chemotherapy, intracavitary | HCPCS | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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. |
96446 | PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH | HCPCS | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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. |
38241 | Transplt autol hct/donor | HCPCS | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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. |
38240 | Transplt allo hct/donor | HCPCS | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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 | 08/26/2015: 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. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: 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 # 8.01.42
Blue Cross Blue Shield Association policy # 8.01.54
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. |
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