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0052T
|
Replace thrc unit hrt syst
|
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.
|
33976
|
PR INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR
|
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.
|
33975
|
PR INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE
|
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.
|
0050T
|
Removal 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.
|
0053T
|
Replace implantable hrt syst
|
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.
|
Q0480
|
Driver pneumatic vad, rep
|
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.
|
0048T
|
Implant ventricular device
|
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.
|
0051T
|
Implant total heart system
|
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.
|
0049T
|
External circulation assist
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
33978
|
Remove ventricular device
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
33977
|
Remove ventricular device
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0052T
|
Replace thrc unit hrt syst
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
33976
|
PR INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
33975
|
PR INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0050T
|
Removal circulation assist
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0053T
|
Replace implantable hrt syst
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
Q0480
|
Driver pneumatic vad, rep
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0048T
|
Implant ventricular device
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0051T
|
Implant total heart system
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. 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. ICD9 2006 revisions added to policy.
|
0049T
|
External circulation assist
|
CPT
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
33978
|
Remove ventricular device
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
33977
|
Remove ventricular device
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0052T
|
Replace thrc unit hrt syst
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
33976
|
PR INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
33975
|
PR INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0050T
|
Removal circulation assist
|
CPT
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0053T
|
Replace implantable hrt syst
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
Q0480
|
Driver pneumatic vad, rep
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0048T
|
Implant ventricular device
|
CPT
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0051T
|
Implant total heart system
|
HCPCS
|
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. ICD9 2006 revisions added to policy. 5/7/2008: Policy description updated.
|
0053T
|
Replace implantable hrt syst
|
HCPCS
|
Ventricular assist devices as destination therapy with end-stage heart failure changed from investigational to medically necessary for FDA-approved devices in patients ineligible for human heart transplant. Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts.
|
0051T
|
Implant total heart system
|
HCPCS
|
Ventricular assist devices as destination therapy with end-stage heart failure changed from investigational to medically necessary for FDA-approved devices in patients ineligible for human heart transplant. Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts.
|
Q4079
|
Natalizumab injection
|
HCPCS
|
Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts. 03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section.
|
0053T
|
Replace implantable hrt syst
|
HCPCS
|
Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts. 03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section.
|
0051T
|
Implant total heart system
|
HCPCS
|
Other policy statements revised for clarity; coverage remains the same. CPT codes 0051T-0053T moved to covered. ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts. 03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section.
|
Q4079
|
Natalizumab injection
|
HCPCS
|
ICD-9 procedure codes 37.52-37.54 moved to covered
9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied
12/31/2008: Code Reference section updated per 2009 CPT/HCPCS revisions
8/19/2009: Policy reviewed, no changes
03/12/2010: Coding Section revised for 2010 CPT4 and HCPCS revision
12/30/2010: Policy description re-written. Policy statements revised to address only implantable VADs and total artificial hearts. 03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section. 12/13/2011: Policy description and statement updated regarding percutaneous ventricular assist devices. Added the following policy statement: Percutaneous ventricular assist devices (pVADs) are considered investigational for all indications.
|
Q4079
|
Natalizumab injection
|
HCPCS
|
Policy statements revised to address only implantable VADs and total artificial hearts. 03/09/2011: Added new HCPCS codes Q4078 and Q4079 to the Code Reference section. 12/13/2011: Policy description and statement updated regarding percutaneous ventricular assist devices. Added the following policy statement: Percutaneous ventricular assist devices (pVADs) are considered investigational for all indications. 11/30/2012: Added the verbiage "or are undergoing evaluation to determine candidacy for heart transplantation" to the policy statement regarding total artificial hearts.
|
0048T
|
Implant ventricular device
|
CPT
|
Replaced "cleared devices" with "clearance." Added "Implantable" to the beggining of the policy statement under the Bridge to Transplantation section. Policy statement on implantable VADs as a bridge to heart tranplantation in children was revised to change the age range from "5 to 16" to "16 years old or younger," reflecting the approval of the BERLIN heart EXCOR device for pediatric patients. Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section.
|
0050T
|
Removal circulation assist
|
CPT
|
Replaced "cleared devices" with "clearance." Added "Implantable" to the beggining of the policy statement under the Bridge to Transplantation section. Policy statement on implantable VADs as a bridge to heart tranplantation in children was revised to change the age range from "5 to 16" to "16 years old or younger," reflecting the approval of the BERLIN heart EXCOR device for pediatric patients. Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section.
|
0048T
|
Implant ventricular device
|
CPT
|
Policy statement on implantable VADs as a bridge to heart tranplantation in children was revised to change the age range from "5 to 16" to "16 years old or younger," reflecting the approval of the BERLIN heart EXCOR device for pediatric patients. Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational.
|
0050T
|
Removal circulation assist
|
CPT
|
Policy statement on implantable VADs as a bridge to heart tranplantation in children was revised to change the age range from "5 to 16" to "16 years old or younger," reflecting the approval of the BERLIN heart EXCOR device for pediatric patients. Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational.
|
0048T
|
Implant ventricular device
|
CPT
|
Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational. 08/27/2015: Code Reference section updated for ICD-10.
|
0050T
|
Removal circulation assist
|
CPT
|
Policy guidelines updated to include coagulation disorders and inadequate psychosocial support as contraindications for bridge to transplant VADs and TAH. Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational. 08/27/2015: Code Reference section updated for ICD-10.
|
0048T
|
Implant ventricular device
|
CPT
|
Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted CPT code Q0505.
|
0050T
|
Removal circulation assist
|
CPT
|
Removed deleted CPT codes 0048T and 0050T from the Code Reference section. 07/07/2015: Code Reference section updated to add Investigational Codes table. CPT codes 33990, 33991, 33992, 33993 and ICD-9 procedure code 37.68 moved from Covered to Investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted CPT code Q0505.
|
L8684
|
Radiof trsmtr implt scrl neu
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8689
|
SYSTEM CHARGING AXONICS WRELS
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8680
|
KIT NRSTM 40CM STIMLOC .
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8683
|
TRANSMITTER SGL
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8682
|
Implt neurostim radiofq rec
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8681
|
REMOTE SLEEP
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8686
|
Implt nrostm pls gen sng non
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8687
|
KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8685
|
Implt nrostm pls gen sng rec
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8688
|
Implt nrostm pls gen dua non
|
HCPCS
|
PMID 19732075
- National Institute for Health and Care Excellence. IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services.
|
L8684
|
Radiof trsmtr implt scrl neu
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8689
|
SYSTEM CHARGING AXONICS WRELS
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8680
|
KIT NRSTM 40CM STIMLOC .
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8683
|
TRANSMITTER SGL
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8682
|
Implt neurostim radiofq rec
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8681
|
REMOTE SLEEP
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8686
|
Implt nrostm pls gen sng non
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8687
|
KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8685
|
Implt nrostm pls gen sng rec
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8688
|
Implt nrostm pls gen dua non
|
HCPCS
|
IPG452 Occipital nerve stimulation for intractable chronic migraine. 2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged.
|
L8684
|
Radiof trsmtr implt scrl neu
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8689
|
SYSTEM CHARGING AXONICS WRELS
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8680
|
KIT NRSTM 40CM STIMLOC .
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8683
|
TRANSMITTER SGL
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8682
|
Implt neurostim radiofq rec
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8681
|
REMOTE SLEEP
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8686
|
Implt nrostm pls gen sng non
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8687
|
KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8685
|
Implt nrostm pls gen sng rec
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8688
|
Implt nrostm pls gen dua non
|
HCPCS
|
2013; http://publications.nice.org.uk/occipital-nerve-stimulation-for-intractable-chronic-migraine-ipg452. Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8684
|
Radiof trsmtr implt scrl neu
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8689
|
SYSTEM CHARGING AXONICS WRELS
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8680
|
KIT NRSTM 40CM STIMLOC .
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8683
|
TRANSMITTER SGL
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8682
|
Implt neurostim radiofq rec
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8681
|
REMOTE SLEEP
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8686
|
Implt nrostm pls gen sng non
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8687
|
KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8685
|
Implt nrostm pls gen sng rec
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8688
|
Implt nrostm pls gen dua non
|
HCPCS
|
Accessed September 9, 2014. |CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8684
|
Radiof trsmtr implt scrl neu
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8689
|
SYSTEM CHARGING AXONICS WRELS
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8680
|
KIT NRSTM 40CM STIMLOC .
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8683
|
TRANSMITTER SGL
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8682
|
Implt neurostim radiofq rec
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8681
|
REMOTE SLEEP
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8686
|
Implt nrostm pls gen sng non
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8687
|
KIT NEUROSTIMULATOR SENZA IPG STERILE LATEX FREE DISPOSABLE
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8685
|
Implt nrostm pls gen sng rec
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
L8688
|
Implt nrostm pls gen dua non
|
HCPCS
|
|CPT||See Policy Guidelines|
|ICD-9 Diagnosis||Investigational for all diagnoses|
|HCPCS||L8680||Implantable neurostimulator electrode, each|
|L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689||Implantable neurostimulator programmer and pulse generator code range|
|ICD-10-CM (effective 10/1/15)||Investigational for all diagnoses|
|G43.00-G43.919||Migraine code range|
|G44.00-G44.89||Other headache syndromes code range|
|ICD-10-PCS (effective 10/1/15)||ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.|
|00HE0MZ, 00HE3MZ, 00HE4MZ||Surgical, central nervous system, insertion, cranial nerve, neurostimulator lead, code by approach|
|00PE0MZ, 00PE3MZ, 00PE4MZ||Surgical, central nervous system, removal, cranial nerve, neurostimulator lead, code by approach|
|0JH60M6, 0JH60M7, 0JH60M8, 0JH60M9, 0JH63M6, 0JH63M7,
0JH63M8, 0JH63M9, 0JH80M6, 0JH80M7, 0JH80M8, 0JH80M9, 0JH83M6, 0JH83M7, 0JH83M8, 0JH83M9
|Surgical, subcutaneous tissue and fascia, insertion, stimulator generator, code by body part (chest or abdomen), approach, number of arrays and whether rechargeable or not|
|0JPT0MZ, 0JPT3MZ||Surgical, subcutaneous tissue and fascia, removal, subcutaneous tissue and fascia, trunk, stimulator generator, code by approach|
|02/11/2010||Add policy to Surgery section||New policy|
|2/10/11||Replace policy||Policy updated with literature search, reference 6 updated, reference 7 added; policy statement unchanged. CPT coding updated in Policy Guidelines.|
|11/10/11||Replace policy||Policy updated with literature search through August 2011; references 7 and 8 added and references reordered; policy statement unchanged|
|11/08/12||Replace Policy||Policy updated with literature search through August 2012; references 2 and 10 added and references reordered; policy statement unchanged|
|11/14/13||Replace policy||Policy updated with literature review through September 27, 2013; references 2 and 13 added; policy statement unchanged|
|11/13/14||Replace policy||Policy updated with literature review through October 7, 2014; reference 3 added; some references removed; policy statement unchanged|
|
G0281
|
PR ELEC STIM UNATTEND FOR PRESS
|
HCPCS
|
Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
|
G0282
|
HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE
|
HCPCS
|
Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
|
G0329
|
PR ELECTROMAGNTIC TX FOR ULCERS
|
HCPCS
|
Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
|
G0295
|
Electromagnetic therapy onc
|
HCPCS
|
Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
|
G0281
|
PR ELEC STIM UNATTEND FOR PRESS
|
HCPCS
|
Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment:
G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
|
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