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J8700 | Temozolomide per 5 mg | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
J8700 | Temozolomide per 5 mg | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
J8700 | Temozolomide per 5 mg | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | The ICD-10 codes are applicable for hospital inpatient procedures. ICD-10-PCS (Procedure Coding System), designed by 3M Health Information Management for Centers of Medicare and Medicaid, is the code set to replace the Volume 3 of ICD-9-CM for inpatient procedure reporting. This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | ICD-10-PCS (Procedure Coding System), designed by 3M Health Information Management for Centers of Medicare and Medicaid, is the code set to replace the Volume 3 of ICD-9-CM for inpatient procedure reporting. This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. It also enhances the quality of healthcare offered to patients. |
1000 | HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT | RC | This ICD-10-PCS has approx. 71000 alpha-numeric codes which has seven digits. Structure of ICD-10-PCS Codes:
In the structure,
For the example shown above, ICD-10 code for knee joint replacement (0SRC0JZ – Replacement of Right Knee Joint with Synthetic Substitute, Open Approach) means the following:
For more information on ICD-10-PCD codes, click here: http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp
Moving to ICD-10 will speed up the medical reimbursement process in the industry and reduce the payment errors. It also enhances the quality of healthcare offered to patients. The Department of Health & Human Services (HHS) published the final rules for adoption of new HIPAA standards on January 16, 2009. |
61867 | PR STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
62258 | Replace brain cavity shunt | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8680 | KIT NRSTM 40CM STIMLOC . | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
36514 | PR THERAPEUTIC APHERESIS PLASMA PHERESIS | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8682 | Implt neurostim radiofq rec | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
90283 | HC IMMUNE GLOBULIN IGIV HUMAN IV USE | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
99183 | PR PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J9218 | LEUPROLIDE ACETATE, PER 1 MG | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
90281 | Human ig im | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J3145 | TESTOSTERONE UNDECANOATE 750 MG/3ML IM SOLN | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61868 | PR STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95975 | Cranial neurostim complex | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
63740 | PR CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
E0203 | Therapeutic lightbox tabletp | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95979 | Analyz neurostim brain addon | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1060 | TESTOSTERONE CYPIONATE, TO 1ML, INJ | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8685 | Implt nrostm pls gen sng rec | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8689 | SYSTEM CHARGING AXONICS WRELS | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1410 | MHS PEDS CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J3121 | testosterone enanthate 200 mg/mL oil 5 mL Vial | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8681 | REMOTE SLEEP | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1950 | PR LEUPROLIDE ACETATE /3.75 MG | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8688 | Implt nrostm pls gen dua non | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
A4633 | Uvl replacement bulb | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
36515 | Apheresis adsorp/reinfuse | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
G0277 | PR HBOT, FULL BODY CHAMBER, 30M | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8695 | External recharg sys extern | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1380 | Injection, estradiol valerate, up to 10 mg | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1572 | IVIG FLEBOGAMMA 500 MGJW | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1000 | INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J9217 | LUPRON DEPOT IM 1 MONTH PWD FOR SUSP 7.5 | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
62180 | PR VENTRICULOCISTERNOSTOMY | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
38240 | Transplt allo hct/donor | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61864 | PR STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
98960 | PR EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J0900 | TESTOSTERONE ENANTHATE, TO 1CC, INJ | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8683 | TRANSMITTER SGL | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
62160 | PR NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95978 | Analyze neurostim brain/1h | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
A4575 | Hyperbaric o2 chamber disps | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
64553 | PR PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
E0446 | Topical ox deliver sys, nos | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8686 | Implt nrostm pls gen sng non | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
36516 | PR THER APHERESIS W/EXTRACORPOREAL IMMUNOADSORPTION | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
S0190 | MIFEPRISTONE ORAL 200 MG | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61880 | Revise/remove neuroelectrode | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61863 | PR STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95974 | Cranial neurostim complex | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1050 | MEDRXYPRGTRN 150MG INJ Injectable Drugs Not on Fee Schedule | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1569 | ORAL IMMUNE GLOBULIN (GAMMAGARD LIQUID) 10% | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1568 | OCTAGAM INJECTION | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
63746 | Removal of spinal shunt | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
C1778 | VNS THERAPY PERENNIAL FLEX | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
C1816 | USER KIT - NALU MEDICAL | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1561 | ORAL IMMUNE GLOBULIN (GAMUNEX-C) 10% | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1953 | levetriracetam per 10 mg | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1459 | PRIVIGEN 1 G/10 ML IV SOLN (WRAPPED) | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61885 | PR INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1071 | TESTOSTRONE CYP 1MG 200MG 1ML SNIJ | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
S2107 | Adoptive immunotherapy | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
38242 | Transplt allo lymphocytes | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8687 | KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1438 | Injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1566 | IVIG POWDER NOS 10 G | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
C1767 | VERCISE GENUS R16 IPG KIT | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J9219 | Leuprolide acetate implant, 65 mg | HCPCS | It could be used as add-on therapy to potentiate the effect of available AChEIs in AD. Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61867 | PR STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
62258 | Replace brain cavity shunt | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8680 | KIT NRSTM 40CM STIMLOC . | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
36514 | PR THERAPEUTIC APHERESIS PLASMA PHERESIS | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8682 | Implt neurostim radiofq rec | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
90283 | HC IMMUNE GLOBULIN IGIV HUMAN IV USE | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
99183 | PR PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J9218 | LEUPROLIDE ACETATE, PER 1 MG | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
90281 | Human ig im | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J3145 | TESTOSTERONE UNDECANOATE 750 MG/3ML IM SOLN | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
61868 | PR STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95975 | Cranial neurostim complex | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
63740 | PR CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
E0203 | Therapeutic lightbox tabletp | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
95979 | Analyz neurostim brain addon | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1060 | TESTOSTERONE CYPIONATE, TO 1ML, INJ | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8685 | Implt nrostm pls gen sng rec | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8689 | SYSTEM CHARGING AXONICS WRELS | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1410 | MHS PEDS CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J3121 | testosterone enanthate 200 mg/mL oil 5 mL Vial | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
L8681 | REMOTE SLEEP | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
J1950 | PR LEUPROLIDE ACETATE /3.75 MG | HCPCS | Nevertheless, results from ongoing phase III trials are needed to verify whether this drug has a significant clinical effect on cognition in association with AChEIs. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes not covered for indications listed in the CPB:|
|36514||Therapeutic apheresis; for plasma pheresis|
|36515||with extracorporeal immunoadsorption and plasma reinfusion|
|36516||with extracorporeal selective adsorption or selective filtration and plasma reinfusion|
|38240||Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor|
|38242||Allogeneic lymphocyte infusions|
|61863||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array|
|+ 61864||each additional array (List separately in addition to primary procedure)|
|61867||Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array|
|+ 61868||each additional array (List separately in addition to primary procedure)|
|61880||Revision or removal of intracranial neurostimulator electrodes|
|61885||Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array|
|+ 62160||Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)|
|62180 - 62258||Cerebrospinal fluid (CSF shunt)|
|63740 - 63746||Shunt, spinal CSF|
|64553||Percutaneous implantation of neurostimulator electrodes; cranial nerve|
|90281 - 90283||Immune globulin (Ig), human|
|99183||Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session|
|95974||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour|
|+ 95975||complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|95978||Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour|
|+ 95979||each additional 30 minutes after first hour (List separately in addition to code for primary procedure)|
|98960||Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient [Applied Behavioral Analysis]|
|HCPCS codes not covered for indications listed in the CPB:|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4633||Replacement bulb/lamp for ultraviolet light therapy system, each|
|C1767||Generator, neurostimulator (implantable), nonrechargeable|
|C1778||Lead, neurostimulator (implantable)|
|C1816||Receiver and/or transmitter, neurostimulator (implantable)|
|E0203||Therpeutic lightbox, minimum 10,000 lux table top model|
|E0446||Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories|
|G0277||Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval|
|J0900||Injection, testosterone enanthate and estradiol valerate, up to 1cc|
|J1000||Injection, depo-estradiol cypionate, up to 5 mg|
|J1050||Injection, medroxyprogesterone acetate, 1 mg|
|J1060||Injection, testosterone cypionate and estradiol cypionate, up to 1 ml|
|J1071||Injection, testosterone cypionate, 1 mg|
|J1380||Injection, estradiol valerate, up to 10 mg|
|J1410||Injection, estrogen conjugated, per 25 mg|
|J1438||Injection, etanercept, 25 mg|
|J1459||Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1561||Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg|
|J1566||Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg|
|J1568||Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1569||Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg|
|J1572||Injection, immune globulin, (Flebogamma / Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J1953||Injection, levetiracetam, 10 mg|
|J3121||Injection, testosterone enanthate, 1mg|
|J3145||Injection, testosterone undecanoate, 1 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate implant, 65 mg|
|J9219||Leuprolide acetate, per 1 mg|
|L8680||Implantable neurostimulator electrode, each|
|L8681||Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only|
|L8682||Implantable neurostimulator radiofrequency receiver|
|L8683||Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver|
|L8685||Implantable neurostimulator pulse generator, single array, rechargeable, includes extension|
|L8686||Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension|
|L8687||Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension|
|L8688||Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension|
|L8689||External recharging system for battery (internal) for use with implantable neurostimulator, replacement only|
|L8695||External recharging system for battery (external) for use with implantable neurostimulator, replacement only|
|S0190||Mitepristone, oral, 200 mg|
|S2107||Adoptive immunotherapy i.e., development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment|
|ICD-10 codes not covered for indications listed in the CPB:|
|G30.0 - G30.9||Alzheimer's disease| |
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