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38240	Transplt allo hct/donor	HCPCS	Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
96445	Chemotherapy, intracavitary	HCPCS	Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
96446	PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH	HCPCS	Policy guidelines updated to add medically necessary and investigative definitions. Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
38241	Transplt autol hct/donor	HCPCS	Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
38240	Transplt allo hct/donor	HCPCS	Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
96445	Chemotherapy, intracavitary	HCPCS	Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
96446	PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH	HCPCS	Sources section updated. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. Blue Cross Blue Shield Association policy # 8.01.42 Blue Cross Blue Shield Association policy # 8.01.54 This may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
86580	TUBERSOL PPD	HCPCS	By day 14 after the 2nd dose, the IFN-γ enzyme-linked immunosorbent spot (ELISPOT) responses were similar for Group: 0+28 and Group: 0+7. The authors concluded that overall, a standard dose of IMVAMUNE (0.5 ml of 1 x 10(8) TCID/ml) administered subcutaneously was safe and well-tolerated. A 2nd dose of IMVAMUNE at day 28 compared to day 7 provided greater antibody responses and the maximal number of responders. By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. \|CPT Codes / HCPCS Codes / ICD-9 Codes\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-9 codes covered if selection criteria are met:\| \|V01.3\|\|Contact with or exposure to smallpox\| \|V04.1\|\|Need for prophylactic vaccination and inoculation against smallpox [pre-exposure - see criteria]\| \|Other ICD-9 codes related to the CPB:\| \|050.0 - 050.9\|\|Smallpox\| \|CPT Codes / HCPCS Codes / ICD-10 Codes\| \|Information in the [brackets] below has been added for clarification purposes.
86580	TUBERSOL PPD	HCPCS	The authors concluded that overall, a standard dose of IMVAMUNE (0.5 ml of 1 x 10(8) TCID/ml) administered subcutaneously was safe and well-tolerated. A 2nd dose of IMVAMUNE at day 28 compared to day 7 provided greater antibody responses and the maximal number of responders. By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. \|CPT Codes / HCPCS Codes / ICD-9 Codes\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-9 codes covered if selection criteria are met:\| \|V01.3\|\|Contact with or exposure to smallpox\| \|V04.1\|\|Need for prophylactic vaccination and inoculation against smallpox [pre-exposure - see criteria]\| \|Other ICD-9 codes related to the CPB:\| \|050.0 - 050.9\|\|Smallpox\| \|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:\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-10 codes covered if selection criteria are met:\| \|Z20.89\|\|Contact with and (suspected) exposure to other communicable diseases [smallpox]\| \|Z23\|\|Encounter for immunization [pre-exposure to smallpox - see criteria]\|
86580	TUBERSOL PPD	HCPCS	A 2nd dose of IMVAMUNE at day 28 compared to day 7 provided greater antibody responses and the maximal number of responders. By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. \|CPT Codes / HCPCS Codes / ICD-9 Codes\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-9 codes covered if selection criteria are met:\| \|V01.3\|\|Contact with or exposure to smallpox\| \|V04.1\|\|Need for prophylactic vaccination and inoculation against smallpox [pre-exposure - see criteria]\| \|Other ICD-9 codes related to the CPB:\| \|050.0 - 050.9\|\|Smallpox\| \|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:\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-10 codes covered if selection criteria are met:\| \|Z20.89\|\|Contact with and (suspected) exposure to other communicable diseases [smallpox]\| \|Z23\|\|Encounter for immunization [pre-exposure to smallpox - see criteria]\|
86580	TUBERSOL PPD	HCPCS	By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. \|CPT Codes / HCPCS Codes / ICD-9 Codes\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-9 codes covered if selection criteria are met:\| \|V01.3\|\|Contact with or exposure to smallpox\| \|V04.1\|\|Need for prophylactic vaccination and inoculation against smallpox [pre-exposure - see criteria]\| \|Other ICD-9 codes related to the CPB:\| \|050.0 - 050.9\|\|Smallpox\| \|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:\| \|There is no specific code for small pox vaccine:\| \|Other CPT codes related to the CPB:\| \|86580\|\|Skin test; tuberculosis, intradermal\| \|ICD-10 codes covered if selection criteria are met:\| \|Z20.89\|\|Contact with and (suspected) exposure to other communicable diseases [smallpox]\| \|Z23\|\|Encounter for immunization [pre-exposure to smallpox - see criteria]\|
1500	New Technology - Level 1	APC	The American Academy of Professionals Coders (AAPC) provides physician-based coding certification courses, such as CPC certification. The organization offers both classroom and online training, which can be completed in less than 5 months. The course fee is $1500. The American Health Information Management Association (AHIMA) offers facility-based training courses – both certificate and degree programs. The coding training with AHIMA usually takes about 15 months to complete.
2015	ENDOBUTTON 4X12MM STRL	CDM	However, according to the changes of the 5th revision of DSM, this case should be diagnosed as a “gambling disorder” (Briefing Note: Changes in DSM – V Re: Gambling, n. d.). The reason for reclassification is the need for provision of greater basis for diagnosing and treating this mental condition. Further explanation of the ICDM-9-CM code of the diagnosis reveals that it refers to “mental, behavioral and neurodevelopmental disorders”, 290-319, “Disturbance of conduct, not elsewhere classified”, 312 (2015 ICD-9-CM: 312.31 Pathological gambling, n. d.). In addition, the index 312.3 stands for disorders of impulse control, not elsewhere classified. Furthermore, this index is conversed into F63.0, which is ICD-10-CM classification.
2015	ENDOBUTTON 4X12MM STRL	CDM	The reason for reclassification is the need for provision of greater basis for diagnosing and treating this mental condition. Further explanation of the ICDM-9-CM code of the diagnosis reveals that it refers to “mental, behavioral and neurodevelopmental disorders”, 290-319, “Disturbance of conduct, not elsewhere classified”, 312 (2015 ICD-9-CM: 312.31 Pathological gambling, n. d.). In addition, the index 312.3 stands for disorders of impulse control, not elsewhere classified. Furthermore, this index is conversed into F63.0, which is ICD-10-CM classification. One also suggests that an additional tool for the diagnosis of gambling may be the South Oaks Gambling Screen (SOGS), which is an instrument of 16-items to “rule in” or “rule out” an individual as someone with problem-gambling (Gambling Disorder, 2015).
2015	ENDOBUTTON 4X12MM STRL	CDM	Further explanation of the ICDM-9-CM code of the diagnosis reveals that it refers to “mental, behavioral and neurodevelopmental disorders”, 290-319, “Disturbance of conduct, not elsewhere classified”, 312 (2015 ICD-9-CM: 312.31 Pathological gambling, n. d.). In addition, the index 312.3 stands for disorders of impulse control, not elsewhere classified. Furthermore, this index is conversed into F63.0, which is ICD-10-CM classification. One also suggests that an additional tool for the diagnosis of gambling may be the South Oaks Gambling Screen (SOGS), which is an instrument of 16-items to “rule in” or “rule out” an individual as someone with problem-gambling (Gambling Disorder, 2015). The major aim of SOGS is revealing the hidden issues of gambling such as borrowing, concealing debts from the family and others.
99202	PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES	HCPCS	■ What Would You Do? What Would You Not Do? Case Study 1 When John is entering patient charges from the charge slips, he finds one charge slip on which the physician has checked the code for an expanded problem-focused office visit (99202) for a new patient named Peter Miller. John notices that the patient for whom he has a charge slip has other transactions in the computer from a previous visit about 12 months before the current visit. ■ HEALTHCARE COMMON PROCEDURE CODING SYSTEM LEVEL II CODES HCPCS Level II codes use a five-digit alphanumeric coding system and designate specific services and equipment.
99202	PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES	HCPCS	What Would You Not Do? Case Study 1 When John is entering patient charges from the charge slips, he finds one charge slip on which the physician has checked the code for an expanded problem-focused office visit (99202) for a new patient named Peter Miller. John notices that the patient for whom he has a charge slip has other transactions in the computer from a previous visit about 12 months before the current visit. ■ HEALTHCARE COMMON PROCEDURE CODING SYSTEM LEVEL II CODES HCPCS Level II codes use a five-digit alphanumeric coding system and designate specific services and equipment. Level II codes are used primarily for items and services that do not have Level I (CPT) codes.
99202	PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES	HCPCS	Case Study 1 When John is entering patient charges from the charge slips, he finds one charge slip on which the physician has checked the code for an expanded problem-focused office visit (99202) for a new patient named Peter Miller. John notices that the patient for whom he has a charge slip has other transactions in the computer from a previous visit about 12 months before the current visit. ■ HEALTHCARE COMMON PROCEDURE CODING SYSTEM LEVEL II CODES HCPCS Level II codes use a five-digit alphanumeric coding system and designate specific services and equipment. Level II codes are used primarily for items and services that do not have Level I (CPT) codes. Examples of items with Level II codes include supplies, materials, specific medications, ambulance services, and some procedures.
E0114	PR CRUTCH UNDERARM PAIR NO WOOD	HCPCS	John notices that the patient for whom he has a charge slip has other transactions in the computer from a previous visit about 12 months before the current visit. ■ HEALTHCARE COMMON PROCEDURE CODING SYSTEM LEVEL II CODES HCPCS Level II codes use a five-digit alphanumeric coding system and designate specific services and equipment. Level II codes are used primarily for items and services that do not have Level I (CPT) codes. Examples of items with Level II codes include supplies, materials, specific medications, ambulance services, and some procedures. For example, if a patient is given a pair of metal underarm crutches after a cast is applied, the HCPCS code E0114 would be used to bill Medicare for the crutches.
E0114	PR CRUTCH UNDERARM PAIR NO WOOD	HCPCS	Level II codes are used primarily for items and services that do not have Level I (CPT) codes. Examples of items with Level II codes include supplies, materials, specific medications, ambulance services, and some procedures. For example, if a patient is given a pair of metal underarm crutches after a cast is applied, the HCPCS code E0114 would be used to bill Medicare for the crutches. Note that the code begins with a letter that corresponds to the section of the Level II code manual. All codes are in the format of one letter followed by four digits, and they are arranged alphabetically by the first character and then numerically by the subsequent digits.
1749	Other and unspecified robotic assisted procedure	ICD	And we’re not talking about Instagram pictures of favorite meals or family vacations but clinical data with life-and-death importance. AHA Hospital Statistics show an estimated five billion healthcare claims are adjudicated in the U.S. every year. This accounts for $3.0 trillion in annual healthcare payment. This isn’t just big dollars but a massive amount of clinical and financial data embedded in these coded claims. Even a single ICD-10 code, such as P0716, which specifies a newborn between 1500-1749 grams, tells us a lot about the patient’s risks and expected costs for care.
1749	Other and unspecified robotic assisted procedure	ICD	This accounts for $3.0 trillion in annual healthcare payment. This isn’t just big dollars but a massive amount of clinical and financial data embedded in these coded claims. Even a single ICD-10 code, such as P0716, which specifies a newborn between 1500-1749 grams, tells us a lot about the patient’s risks and expected costs for care. Such low birth weight is likely accompanied by respiratory distress and the need for auxiliary oxygen, hemorrhage potentially causing brain damage, higher risk of heart failure and digestive disorders—not to mention increased long-term risks for diabetes and high blood pressure. The possibilities for AI and computer automation in health care appear limitless.
87797	HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note.
87799	INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note.
87798	VARICELLA ZOSTER PCR	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note.
87797	HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA.
87799	INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA.
87798	VARICELLA ZOSTER PCR	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA.
87798	VARICELLA ZOSTER PCR	HCPCS	POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table.
87641	STAPH AUREUS NASAL PCR	HCPCS	POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table.
87799	INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED_ QUANTIFICATION, EACH ORGANISM	HCPCS	POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table.
87640	STAPH A DNA AMP PROBE	HCPCS	POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table.
87797	HC INFECTIOUS AGENT DETECTION NUCLEIC ACID, NOT OTHERWISE SPECIF	HCPCS	POLICY HISTORY10/26/2006: Policy added 1/2/2007: Code reference section updated per the 2007 CPT/HCPCS revisions. Added CPT 87797 and 87798 to covered table. Added CPT 87799 to non-covered table with see policy note. 5/14/2007: Policy reviewed; updated to include enterovirus, staphylococcus aureus, and MRSA. CPT codes 87640-87641 added to covered table.
G0358	IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0360	Each additional hr 1-8 hrs	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
J9000	INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0364	HC BONE MARROW ASPIRATE & BIOPSY	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0362	Each add sequential infusion	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
J9999	Not otherwise classified, antineoplastic drugs	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0359	Chemotherapy IV one hr initi	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
38230	PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0361	Prolong chemo infuse>8hrs pu	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0357	IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0356	HORMONAL ANTINEOPLASTIC	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0355	CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC	HCPCS	Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated.
G0358	IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
86826	Hla x-match noncytotoxc addl	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
86825	X-MATCHAHG	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0360	Each additional hr 1-8 hrs	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
J9000	INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0364	HC BONE MARROW ASPIRATE & BIOPSY	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0362	Each add sequential infusion	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
J9999	Not otherwise classified, antineoplastic drugs	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0359	Chemotherapy IV one hr initi	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
38230	PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0361	Prolong chemo infuse>8hrs pu	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0357	IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0356	HORMONAL ANTINEOPLASTIC	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0355	CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC	HCPCS	The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table.
G0358	IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
86826	Hla x-match noncytotoxc addl	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
86825	X-MATCHAHG	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0360	Each additional hr 1-8 hrs	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
J9000	INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0364	HC BONE MARROW ASPIRATE & BIOPSY	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0362	Each add sequential infusion	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
J9999	Not otherwise classified, antineoplastic drugs	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0359	Chemotherapy IV one hr initi	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
38230	PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0361	Prolong chemo infuse>8hrs pu	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0357	IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0356	HORMONAL ANTINEOPLASTIC	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0355	CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC	HCPCS	POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31 6/25/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added 3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 8/22/2008: Description section updated; policy statement unchanged 4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes.
G0267	Bone marrow or psc harvest	CPT	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
38240	Transplt allo hct/donor	HCPCS	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
G0265	Cryopresevation Freeze+stora	CPT	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
G0266	Thawing + expansion froz cel	CPT	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
38242	Transplt allo lymphocytes	HCPCS	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
96445	Chemotherapy, intracavitary	HCPCS	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
96446	PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH	HCPCS	10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
G0267	Bone marrow or psc harvest	CPT	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
38240	Transplt allo hct/donor	HCPCS	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0265	Cryopresevation Freeze+stora	CPT	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0266	Thawing + expansion froz cel	CPT	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
38242	Transplt allo lymphocytes	HCPCS	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
96445	Chemotherapy, intracavitary	HCPCS	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
96446	PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH	HCPCS	11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0267	Bone marrow or psc harvest	CPT	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
38240	Transplt allo hct/donor	HCPCS	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0265	Cryopresevation Freeze+stora	CPT	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
G0266	Thawing + expansion froz cel	CPT	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
38242	Transplt allo lymphocytes	HCPCS	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
96445	Chemotherapy, intracavitary	HCPCS	04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revise the descriptions for CPT codes 38240 and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.

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