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31254 | PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31294 | PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
61548 | Removal of pituitary gland | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31288 | PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31287 | PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31276 | PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31290 | PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
S8030 | Tantalum ring application | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31256 | PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
31267 | PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
61795 | Brain surgery using computer | HCPCS | Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. |
S8030 | Tantalum ring application | HCPCS | HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. |
61795 | Brain surgery using computer | HCPCS | HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. |
77372 | Srs linear based | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77432 | Stereotactic radiation trmt | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77522 | Proton trmt simple w/comp | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
63621 | Srs spinal lesion addl | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
61795 | Brain surgery using computer | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
G0243 | MX-SRC PHOTON STERO RADIOSURG DEL W/COLLMTR CHGS | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77373 | Sbrt delivery | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77299 | HC UNLIS PX THER RADIOL CLINICAL TX PLANNING | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77416 | Radiation treatment delivery | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77523 | Proton trmt intermediate | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
63620 | Srs spinal lesion | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77399 | HC UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
61793 | Focus Radiation Beam | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77520 | Proton trmt simple w/o comp | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
61799 | Srs cran les complex addl | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77525 | Proton treatment complex | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
S8030 | Tantalum ring application | HCPCS | CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. |
77372 | Srs linear based | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77432 | Stereotactic radiation trmt | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77522 | Proton trmt simple w/comp | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
63621 | Srs spinal lesion addl | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
61795 | Brain surgery using computer | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
G0243 | MX-SRC PHOTON STERO RADIOSURG DEL W/COLLMTR CHGS | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77373 | Sbrt delivery | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77299 | HC UNLIS PX THER RADIOL CLINICAL TX PLANNING | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77416 | Radiation treatment delivery | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77523 | Proton trmt intermediate | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
63620 | Srs spinal lesion | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77399 | HC UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
61793 | Focus Radiation Beam | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77520 | Proton trmt simple w/o comp | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
61799 | Srs cran les complex addl | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77525 | Proton treatment complex | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
S8030 | Tantalum ring application | HCPCS | ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosugery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. |
77372 | Srs linear based | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77432 | Stereotactic radiation trmt | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77522 | Proton trmt simple w/comp | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
63621 | Srs spinal lesion addl | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77371 | HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61795 | Brain surgery using computer | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
G0243 | MX-SRC PHOTON STERO RADIOSURG DEL W/COLLMTR CHGS | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77373 | Sbrt delivery | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77299 | HC UNLIS PX THER RADIOL CLINICAL TX PLANNING | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77416 | Radiation treatment delivery | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77523 | Proton trmt intermediate | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61781 | Scan proc cranial intra | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
63620 | Srs spinal lesion | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77435 | HC STEREOTACTIC BODY RADIATION MANAGEMENT | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77399 | HC UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61793 | Focus Radiation Beam | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61783 | Scan proc spinal | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77520 | Proton trmt simple w/o comp | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
61799 | Srs cran les complex addl | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
20660 | PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
77525 | Proton treatment complex | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
S8030 | Tantalum ring application | HCPCS | Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotatic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotatic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section. 12/30/2010: Policy statement regarding non-small cell lunger cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary. 02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section. 07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). |
G6011 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6007 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6012 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6003 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6005 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6009 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6013 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6008 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77412 | RAD TRMT DELIVERY, > 1 MEV, COMPL | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
77402 | HC RAD TX> 1MEV, SIMPLE | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6010 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6014 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6004 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
61795 | Brain surgery using computer | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6006 | Radiation treatment delivery | HCPCS | Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. |
G6011 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6007 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
77407 | HC RADIATION TREATMENT DELIVERY | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6012 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6003 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
G6005 | Radiation treatment delivery | HCPCS | Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. |
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