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J9070
|
HC Cyclophosphamide Inj Bu100mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
S2150
|
Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; m
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9120
|
Injection, dactinomycin, 0.5 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9200
|
Injection, floxuridine, 500 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9266
|
PEGASPARGASE VIAL 3750U 5ML SNIJ
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
30243G0
|
Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
38211
|
Tumor cell deplete of harvst
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9093
|
CYCLOPHOSPHAMIDE LYOPHILIZED 100 MG
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9305
|
pemetrexed per 10 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
38232
|
PR BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9027
|
Injection, clofarabine, 1 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9355
|
trastuzumab per 10 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9357
|
Valrubicin injection
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9216
|
Interferon gamma 1-b inj
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9260
|
METHOTREXATE SODIUM (PF) 50 MG/2ML INJ SOLUTION
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9211
|
Injection, idarubicin hydrochloride, 5 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9215
|
Interferon alfa-n3 inj
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9340
|
Thiotepa injection
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9290
|
Mitomycin 20 MG inj
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9025
|
INJECTION, AZACITIDINE, 1 MG
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9300
|
QUINACRINE HCL 10 CC/200 MGM
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
J9219
|
Leuprolide acetate implant, 65 mg
|
HCPCS
|
|CPT||38204||Management of recipient hematopoietic cell donor search and cell acquisition|
|38205||Blood-derived hematopoietic progenitor cell harvesting for transplantaion, per collection, allogeneic|
|38208||Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor|
|38209||;thawing of previously frozen harvest with washing, per donor|
|38210||Specific cell depletion with harvest, T cell depletion|
|38211||Tumor cell depletion|
|38212||Red blood cell removal|
|38214||Plasma (volume) depletion|
|38215||Cell concentration in plasma, mononuclear, or buffy coat layer|
|38220||Bone marrow; aspiration only|
|38221||Bone marrow; biopsy, needle or trocar|
|38230||Bone marrow harvesting for transplantation; allogeneic|
|38232||bone marrow harvesting for transplnation; autologous|
|38240||Bone marrow or blod-derived [eropheral stem-cell transplatation; allogeneic|
|ICD-9 Procedure||41.00||Bone marrow transplant, not otherwise specified|
|41.01||Autologous bone marrow transplant without purging|
|41.02||Allogeneic hone marrow transplant with purging|
|41.03||Allogeneic bone marrow transplant without purging|
|41.04||Autologous hematopoietic stem-cell transplant without purging|
|41.05||Allogeneic hematopoietic stem cell transplant without purging|
|41.06||Cord blood stem cell transplant|
|41.07||Autologous hematopoietic stem-cell transplant with purging|
|41.08||Allogeneic hematopoietic stem-cell transplant with purging|
|41.09||Autologous bone marrow transplant with purging|
|41.91||Aspiration of bone marrow from donor for transplant|
|99.79||Other therapeutic apheresis (includes harvest of stem cells)|
|ICD-9 Diagnosis||191.0–191.9||Malignant neoplasm of brain code range|
|HCPCS||Q0083, Q0084, Q0085||Chemotherapy administration code range|
J9000, J9001, J9010, J9015, J9017, J9020, J9025, J9027, J9031, J9035, J9041, J9045, J9050, J9055, J9060, J9062, J9065, J9070, J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9098, J9100, J9110, J9120, J9130, J9140, J9150, J9151, J9160, J9165, J9170, J9175, J9178, J9181, J9182, J9185, J9190, J9200, J9201, J9202, J9206, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, J9219, J9225, J9226, J9230, J9245, J9250, J9260, J9261, J9263, J9264, J9265, J9266, J9268, J9270, J9280, J9290, J9291, J9293, J9300, J9303, J9305, J9310, J9320, J9340, J9350, J9355, J9357, J9360, J9370, J9375, J9380, J9390, J9395, J9600, J9999
|Chemotherapy drugs code range|
|G0265||Bryopreservation, freezing and storage of cells for thereapeutic use, each cell line|
|G0266||Thawing and expansion of frozen cells for therapeuticuse, each cell line|
|G0267||Bone marrow or peripheral stem-cell harvest, modification or treatment to eliminate cell type(s) (e.g., T cells, metastic carcinoma)|
|S2150||Bone marrow or blood-derived peripheral stem-cell harvesting and transplantation, allogeneic or autologous, including pheresis, high-dose chemotherapy, and the number of days of post-transplant care in the global definition (including drugs; hospitalization; medical surgical, diagnostic and emergency services)|
|ICD-10-CM (effective 10/1/15)||C71.0-C71.9||Malignant neoplasm of brain|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.|
|30243G0, 30243X0, 30243Y0||Percutaneous transfusion, central vein, bone marrow or stem cells, autologous, code list|
|30243G1, 30243X1, 30243Y1||Percutaneous transfusion, central vein, bone marrow or stem cells, nonautologous, code list|
|07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ||Surgical, lymphatic and hemic systems, extraction, bone marrow, code list|
|Type of Service||Therapy|
|Place of Service||Inpatient/Outpatient|
Ependymoma, High-dose Chemotherapy
Ependymoblastoma, High-dose Chemotherapy
High-dose chemotherapy with autologous stem-cell support for PNET and ependymoma
Medulloblastoma, High-dose Chemotherapy
Neuroblastoma, Central, High-dose Chemotherapy
Pinealblastoma, High-dose Chemotherapy
Primitive Neuroectodermal Tumors (PNET), High-dose Chemotherapy
|12/01/99||Add to Therapy section||New policy
Policy represents revision of 8.01.15 to focus entirely on PNET. Policy statement unchanged
|08/15/01||Replace policy||Policy revised to correct type: Page 2 of this policy (under the 2nd “Note”) refers to another policy [No. 8.01.15], but should refer instead to policy No. 8.01.34|
|10/08/02||Replace policy||Policy updated and references added; no change in policy statement|
|07/15/04||Replace policy||Policy updated with literature review for the period of May 2002 through May 2004; policy statement unchanged|
|09/27/05||Replace policy||Policy updated with literature review for the period of May 2004 through August 2005; reference number 3 updated; policy statement unchanged|
|04/17/07||Replace policy||Policy updated with literature search; policy statement added to indicate that multiple-cycle high-dose chemotherapy (with or without associated radiotherapy) and autologous stem-cell support (i.e., tandem transplants) is investigational. Reference number 5 updated; reference numbers 3, 4, and 8 added.
|
90662
|
INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90650
|
HC 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90710
|
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90687
|
Iiv4 vaccine splt 0.25 ml im
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
86762
|
RUBELLA ANTIBODY
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90706
|
Rubella vaccine sc
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90657
|
HC IIV3 VACCINE SPLIT VIRUS 0.25 ML DOSAGE IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90689
|
HC IIV4 VACC INACTIVATED PRSRV FR 0.25ML DOS IM US
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90734
|
Meningococcal vaccine, serogroups A, C, W, Y, diphtheria toxoid carrier vaccine
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90715
|
TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
G0008
|
PR ADMIN INFLUENZA VIRUS VAC
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90707
|
MMR PVT
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90680
|
ROTATEQ PVT
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90688
|
HC IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90686
|
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, PRESERVATIVE FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90649
|
HC HUMAN PAPILOMA VAC 3 DOSE IM
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90673
|
HC RIV3 VACCINE PRESERVATIVE FREE FOR IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90681
|
HC RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90685
|
HC IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90633
|
HEP A (PED) HAVRIX PVT
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90655
|
Iiv3 vacc no prsv 0.25 ml im
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90651
|
HC HUMAN PAPILOMA VAC 3 DOSE IM
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90661
|
HC CCIIV3 VACCINE PRESERVATIVE FREE 0.5 ML IM USE
|
HCPCS
|
To help, the CDC has published vaccine catch-up guidance on their website. Important update from the National Committee for Quality Assurance (NCQA)
NCQA stressed the importance of getting childhood immunizations as soon as possible in a recent webinar, citing the impacts from the possible summer COVID-19 vaccine launch for children. Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90662
|
INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, FOR INTRAMUSCULAR USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90650
|
HC 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90710
|
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90687
|
Iiv4 vaccine splt 0.25 ml im
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
86762
|
RUBELLA ANTIBODY
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90706
|
Rubella vaccine sc
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90657
|
HC IIV3 VACCINE SPLIT VIRUS 0.25 ML DOSAGE IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90689
|
HC IIV4 VACC INACTIVATED PRSRV FR 0.25ML DOS IM US
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90734
|
Meningococcal vaccine, serogroups A, C, W, Y, diphtheria toxoid carrier vaccine
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90715
|
TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
G0008
|
PR ADMIN INFLUENZA VIRUS VAC
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90707
|
MMR PVT
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90680
|
ROTATEQ PVT
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90688
|
HC IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90686
|
INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, PRESERVATIVE FREE, 0.5 ML DOSAGE, FOR INTRAMUSCULAR USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90649
|
HC HUMAN PAPILOMA VAC 3 DOSE IM
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90673
|
HC RIV3 VACCINE PRESERVATIVE FREE FOR IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90681
|
HC RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90685
|
HC IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90633
|
HEP A (PED) HAVRIX PVT
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90655
|
Iiv3 vacc no prsv 0.25 ml im
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90651
|
HC HUMAN PAPILOMA VAC 3 DOSE IM
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
90661
|
HC CCIIV3 VACCINE PRESERVATIVE FREE 0.5 ML IM USE
|
HCPCS
|
Vaccine physicians are being advised that children should not receive any other vaccinations two weeks prior to or two weeks after receiving a COVID-19 vaccine. They re-emphasized the significance of delay and suggest that childhood immunizations are administered as soon as needed through proactively scheduling and preplanning. Helpful information for keeping babies and children healthy
Childhood Immunization Schedule (CIS) HEDIS® measures require that all children are immunized by the age of two:
- Four DTaP (diphtheria, tetanus and acellular pertussis)
- Three IPV (polio)
- One MMR (measles, mumps, rubella)
- Three HiB (H influenza type B)
- Three HepB (hepatitis B)
- One VZV (chicken pox)
- Four PCV (pneumococcal conjugate)
- One HepA (hepatitis A)
- Two or Three RV (rotavirus)
- Two Influenza (flu)
- MMR CPT: 90707, 90710 ICD-10-CM: B05.0-4, B05.81, B05.89, B05.9
- Mumps ICD-10-CM: B26.0-3, B26.81-85, B26.89, B26.9
- Rubella ICD-10-CM: B06.00-02, B06.09, B06.81-82, B06.89, B06.9
- Rubella CPT: 90706
- Rubella antibody CPT: 86762
- Hepatitis A (Hep A) CPT: 90633 ICD-10-CM: B15.0, B15.9
- Influenza CPT: 90655, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, 90689
- HCPCS: G0008
- Rotavirus vaccine (RV) CPT: 90681 (two-dose) and 90680 (three-dose)
Children should be fully immunized by 13 years of age to meet the Immunization for Adolescents (IMA) HEDIS® measure:
- 1 Meningococcal vaccine (MCV) injection between 11 to 13 years of age
- 1 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap/Td) between
10 to 13 years of age
- 2 or 3 HPV vaccines between 9 to 13 years of age
- Meningococcal CPT: 90734
- Tdap CPT: 90715
- HPV CPT: 90649, 90650, 90651
April 2021 Anthem Provider News - Virginia
|
86580
|
TUBERSOL PPD
|
HCPCS
|
The authors concluded that overall, a standard dose of IMVAMUNE (0.5 ml of 1 x 10(8) TCID/ml) administered subcutaneously was safe and well-tolerated. A 2nd dose of IMVAMUNE at day 28 compared to day 7 provided greater antibody responses and the maximal number of responders. By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|There is no specific code for small pox vaccine:|
|Other CPT codes related to the CPB:|
|86580||Skin test; tuberculosis, intradermal|
|ICD-10 codes covered if selection criteria are met:|
|Z20.89||Contact with and (suspected) exposure to other communicable diseases [smallpox]|
|Z23||Encounter for immunization [pre-exposure to smallpox - see criteria]|
|
86580
|
TUBERSOL PPD
|
HCPCS
|
A 2nd dose of IMVAMUNE at day 28 compared to day 7 provided greater antibody responses and the maximal number of responders. By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|There is no specific code for small pox vaccine:|
|Other CPT codes related to the CPB:|
|86580||Skin test; tuberculosis, intradermal|
|ICD-10 codes covered if selection criteria are met:|
|Z20.89||Contact with and (suspected) exposure to other communicable diseases [smallpox]|
|Z23||Encounter for immunization [pre-exposure to smallpox - see criteria]|
|
86580
|
TUBERSOL PPD
|
HCPCS
|
By day 14 after the 2nd dose, IFN-γ ELISPOT responses were similar for Group: 0+28 and Group: 0+7. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|There is no specific code for small pox vaccine:|
|Other CPT codes related to the CPB:|
|86580||Skin test; tuberculosis, intradermal|
|ICD-10 codes covered if selection criteria are met:|
|Z20.89||Contact with and (suspected) exposure to other communicable diseases [smallpox]|
|Z23||Encounter for immunization [pre-exposure to smallpox - see criteria]|
|
E1340
|
Repair for DME - per 15 min
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
A4556
|
PT ELECTRODES
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
E0608
|
APNEA MONITOR
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
A4557
|
Lead wires, pair
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
E0619
|
Apnea monitor w recorder
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
E0618
|
Apnea monitor, without recording feature
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement.
|
E1340
|
Repair for DME - per 15 min
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
A4556
|
PT ELECTRODES
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
E0608
|
APNEA MONITOR
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
A4557
|
Lead wires, pair
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
E0619
|
Apnea monitor w recorder
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
E0618
|
Apnea monitor, without recording feature
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy.
|
E1340
|
Repair for DME - per 15 min
|
CPT
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
A4556
|
PT ELECTRODES
|
HCPCS
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
E0608
|
APNEA MONITOR
|
HCPCS
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
A4557
|
Lead wires, pair
|
HCPCS
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
E0619
|
Apnea monitor w recorder
|
HCPCS
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
E0618
|
Apnea monitor, without recording feature
|
HCPCS
|
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medially necessary. The coverage guidelines outlined in the Medical Policy should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement. The intent of the policy statements unchanged.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
The intent of the policy statements unchanged. FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged. 04/04/2013: Policy reviewed; no changes.
|
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