code
stringlengths 4
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| description
stringlengths 2
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| codetype
stringclasses 8
values | context
stringlengths 160
15.5k
|
|---|---|---|---|
77326
|
Brachytx isodose calc simp
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
C2639
|
SEED BRACHYTHERAPY IODINE-125 NEEDLE LOOSE TRAY STERILE
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77762
|
HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
76965
|
Echo guidance radiotherapy
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
Q3001
|
Radioelements for brachytherapy, any type, each
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77327
|
Brachytx isodose calc interm
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
C2640
|
HC Palladium-103 Stranded
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77404
|
Radiation treatment delivery
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77799
|
HC UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77778
|
HC ASRG INTERSTIT RADIOELEM APPLI
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77403
|
Radiation treatment delivery
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
55859
|
Percut/needle insert, pros
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77761
|
HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77406
|
Radiation treatment delivery
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77328
|
Brachytx isodose plan compl
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77777
|
Apply interstit radiat inter
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
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. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
76873
|
HC PROSTATE VOLUME STUDY
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77763
|
HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
77776
|
Apply interstit radiat simpl
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
C2641
|
HC Palladium-103 Seed
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table.
|
C1715
|
SET BRACHYTHERAPY 20CM BEVEL 18GA 2 PART HUB DESIGN STABILIZATION
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77326
|
Brachytx isodose calc simp
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
C2639
|
SEED BRACHYTHERAPY IODINE-125 NEEDLE LOOSE TRAY STERILE
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77762
|
HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
76965
|
Echo guidance radiotherapy
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
Q3001
|
Radioelements for brachytherapy, any type, each
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77327
|
Brachytx isodose calc interm
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
C2640
|
HC Palladium-103 Stranded
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77404
|
Radiation treatment delivery
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77799
|
HC UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77778
|
HC ASRG INTERSTIT RADIOELEM APPLI
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77403
|
Radiation treatment delivery
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
55859
|
Percut/needle insert, pros
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77761
|
HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77406
|
Radiation treatment delivery
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77328
|
Brachytx isodose plan compl
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77777
|
Apply interstit radiat inter
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
76873
|
HC PROSTATE VOLUME STUDY
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77763
|
HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
77776
|
Apply interstit radiat simpl
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
C2641
|
HC Palladium-103 Seed
|
HCPCS
|
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table. 7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
77318
|
HC BRACHYTX ISODOSE PLAN, CPLX
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
77316
|
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
77317
|
HC BRACHYTX ISODOSE PLAN, INTRMED
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
77318
|
HC BRACHYTX ISODOSE PLAN, CPLX
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
77316
|
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
77317
|
HC BRACHYTX ISODOSE PLAN, INTRMED
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
77318
|
HC BRACHYTX ISODOSE PLAN, CPLX
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
77316
|
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
77317
|
HC BRACHYTX ISODOSE PLAN, INTRMED
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
|
C2699
|
Brachytx, non-stranded, NOS
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2637
|
Brachy,non-str,Ytterbium-169
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2642
|
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2698
|
Brachytx, stranded, NOS
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2636
|
HC Civastring P103/Mm Cms Study
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2643
|
HB CESIUM 131 NS SEED PER SOURCE
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
|
C2699
|
Brachytx, non-stranded, NOS
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2642
|
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2637
|
Brachy,non-str,Ytterbium-169
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2698
|
Brachytx, stranded, NOS
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2636
|
HC Civastring P103/Mm Cms Study
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2643
|
HB CESIUM 131 NS SEED PER SOURCE
|
HCPCS
|
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
|
C2699
|
Brachytx, non-stranded, NOS
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2642
|
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2637
|
Brachy,non-str,Ytterbium-169
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2698
|
Brachytx, stranded, NOS
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2636
|
HC Civastring P103/Mm Cms Study
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2643
|
HB CESIUM 131 NS SEED PER SOURCE
|
HCPCS
|
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy."
|
C2699
|
Brachytx, non-stranded, NOS
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
C2642
|
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
C2637
|
Brachy,non-str,Ytterbium-169
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
C2698
|
Brachytx, stranded, NOS
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
C2636
|
HC Civastring P103/Mm Cms Study
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
C2643
|
HB CESIUM 131 NS SEED PER SOURCE
|
HCPCS
|
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated regarding permanent low-dose rate brachytherapy in the treatment of localized prostate cancer.
|
0049T
|
External circulation assist
|
CPT
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. 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. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
3/2003: Reviewed by MPAC; Policy title "Ventricular Assist Devices as a Bridge to Heart Transplantation" renamed "Ventricular Assist Devices", LVAD as a "destination" therapy considered investigational. FEP exception added
7/24/2003: Code References section updated, ICD-9 procedure code 37.61 deleted, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 added covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 added non-covered codes
3/2004: Reviewed by MPAC, coverage remains as written with policy statement added to limit medically necessary indications to FDA approved ventricular assist devices, total artificial hearts are considered investigational, Policy title “Ventricular Assist Devices” renamed “Ventricular Assist Devices and Total Artificial Hearts", Description section revised to be consistent with BCBSA policy # 7.03.11, FEP exceptions added, Sources added, “contraindications” moved from Policy to Policy Guidelines section
10/13/2004: Code Reference section updated, CPT code 0048T, 0049T, 0050T added covered codes, CPT 33975, 33976, 33977, 33978 description revised, ICD-9 procedure code 37.62, 37.63, 37.66 description revised, ICD-9 procedure code 37.68 added, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 deleted covered codes, CPT 0051T, 0052T, 0053T added non-covered codes, ICD-9 procedure code 37.52, 37.53, 37.54 added non-covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 deleted non-covered codes
11/11/2005: Code Reference section updated, HCPCS codes Q0480-Q0505 added
4/10/2006: Policy reviewed, no change to policy. Q0480-Q0505 already added to policy
9/6/2006: Policy updated to include information on the AbioCor artificial heart
9/18/2006: Coding revised.
|
33978
|
Remove ventricular device
|
HCPCS
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. 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. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
3/2003: Reviewed by MPAC; Policy title "Ventricular Assist Devices as a Bridge to Heart Transplantation" renamed "Ventricular Assist Devices", LVAD as a "destination" therapy considered investigational. FEP exception added
7/24/2003: Code References section updated, ICD-9 procedure code 37.61 deleted, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 added covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 added non-covered codes
3/2004: Reviewed by MPAC, coverage remains as written with policy statement added to limit medically necessary indications to FDA approved ventricular assist devices, total artificial hearts are considered investigational, Policy title “Ventricular Assist Devices” renamed “Ventricular Assist Devices and Total Artificial Hearts", Description section revised to be consistent with BCBSA policy # 7.03.11, FEP exceptions added, Sources added, “contraindications” moved from Policy to Policy Guidelines section
10/13/2004: Code Reference section updated, CPT code 0048T, 0049T, 0050T added covered codes, CPT 33975, 33976, 33977, 33978 description revised, ICD-9 procedure code 37.62, 37.63, 37.66 description revised, ICD-9 procedure code 37.68 added, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 deleted covered codes, CPT 0051T, 0052T, 0053T added non-covered codes, ICD-9 procedure code 37.52, 37.53, 37.54 added non-covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 deleted non-covered codes
11/11/2005: Code Reference section updated, HCPCS codes Q0480-Q0505 added
4/10/2006: Policy reviewed, no change to policy. Q0480-Q0505 already added to policy
9/6/2006: Policy updated to include information on the AbioCor artificial heart
9/18/2006: Coding revised.
|
33977
|
Remove ventricular device
|
HCPCS
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. 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. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
3/2003: Reviewed by MPAC; Policy title "Ventricular Assist Devices as a Bridge to Heart Transplantation" renamed "Ventricular Assist Devices", LVAD as a "destination" therapy considered investigational. FEP exception added
7/24/2003: Code References section updated, ICD-9 procedure code 37.61 deleted, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 added covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 added non-covered codes
3/2004: Reviewed by MPAC, coverage remains as written with policy statement added to limit medically necessary indications to FDA approved ventricular assist devices, total artificial hearts are considered investigational, Policy title “Ventricular Assist Devices” renamed “Ventricular Assist Devices and Total Artificial Hearts", Description section revised to be consistent with BCBSA policy # 7.03.11, FEP exceptions added, Sources added, “contraindications” moved from Policy to Policy Guidelines section
10/13/2004: Code Reference section updated, CPT code 0048T, 0049T, 0050T added covered codes, CPT 33975, 33976, 33977, 33978 description revised, ICD-9 procedure code 37.62, 37.63, 37.66 description revised, ICD-9 procedure code 37.68 added, ICD-9 diagnosis 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 deleted covered codes, CPT 0051T, 0052T, 0053T added non-covered codes, ICD-9 procedure code 37.52, 37.53, 37.54 added non-covered codes, ICD-9 diagnosis 038.0-038.9, 042, 090.0-097.9, 112.5, 117.5, 280.0-282.63, 282.69-289.51, 289.59-289.9, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 518.83, 518.84, 570, 571.0, 571.1, 571.2, 571.3, 572.4, 572.8, 585 deleted non-covered codes
11/11/2005: Code Reference section updated, HCPCS codes Q0480-Q0505 added
4/10/2006: Policy reviewed, no change to policy. Q0480-Q0505 already added to policy
9/6/2006: Policy updated to include information on the AbioCor artificial heart
9/18/2006: Coding revised.
|
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