code
stringlengths 4
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stringlengths 2
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| codetype
stringclasses 8
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stringlengths 160
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|---|---|---|---|
90379
|
Rsv Ig, Iv
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
90378
|
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
90772
|
Ther/Proph/Diag Inj, Sc/Im
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
90766
|
Ther/Proph/Dg Iv Inf, Add-On
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
J1565
|
RSV-ivig
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
90765
|
Ther/Proph/Diag Iv Inf, Init
|
HCPCS
|
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted.
|
90379
|
Rsv Ig, Iv
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
90378
|
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
90772
|
Ther/Proph/Diag Inj, Sc/Im
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
90766
|
Ther/Proph/Dg Iv Inf, Add-On
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
J1565
|
RSV-ivig
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
90765
|
Ther/Proph/Diag Iv Inf, Init
|
HCPCS
|
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
|
90379
|
Rsv Ig, Iv
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
90378
|
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
90772
|
Ther/Proph/Diag Inj, Sc/Im
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
90766
|
Ther/Proph/Dg Iv Inf, Add-On
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
J1565
|
RSV-ivig
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
90765
|
Ther/Proph/Diag Iv Inf, Init
|
HCPCS
|
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication. 11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added. 01/01/2009: Accredo preferred provider information removed.
|
90379
|
Rsv Ig, Iv
|
HCPCS
|
Maximum of 5 doses/season added to infant age specifications. Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section.
|
J1565
|
RSV-ivig
|
HCPCS
|
Maximum of 5 doses/season added to infant age specifications. Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section.
|
90379
|
Rsv Ig, Iv
|
HCPCS
|
Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10.
|
J1565
|
RSV-ivig
|
HCPCS
|
Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10.
|
90379
|
Rsv Ig, Iv
|
HCPCS
|
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy number added.
|
J1565
|
RSV-ivig
|
HCPCS
|
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy number added.
|
0379
|
Anesthesia - Other Anesthesia
|
RC
|
Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)A search of the literature was completed through the MEDLINE database.
|
L8604
|
SYRINGE DEFLUX INJ PREFILL 1ML GLASS
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
Q3031
|
Collagen skin test
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
78740
|
Ureteral reflux study
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
52327
|
PR CYSTO W/SUBURTRIC NJX IMPLT MATRL
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74455
|
X-ray urethra/bladder
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74450
|
X-ray urethra/bladder
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
L8606
|
SYRINGE DURASPHERE EXP 1ML
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74420
|
Urography rtrgr +-kub
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
L8603
|
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
|
HCPCS
|
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
L8604
|
SYRINGE DEFLUX INJ PREFILL 1ML GLASS
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
Q3031
|
Collagen skin test
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
78740
|
Ureteral reflux study
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
52327
|
PR CYSTO W/SUBURTRIC NJX IMPLT MATRL
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74455
|
X-ray urethra/bladder
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74450
|
X-ray urethra/bladder
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
L8606
|
SYRINGE DURASPHERE EXP 1ML
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
74420
|
Urography rtrgr +-kub
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
L8603
|
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
|
HCPCS
|
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|52327||Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material|
|Other CPT codes related to the CPB:|
|74420||Urography, retrograde, with or without KUB|
|74450||Urethrocystography, retrograde, radiological supervision and interpretation|
|74455||Urethrocystography, voiding, radiological supervision and interpretation|
|78740||Ureteral reflux study (radiopharmaceutical voiding cystogram)|
|HCPCS codes covered if selection criteria are met:|
|L8604||Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies|
|L8606||Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies|
|Q3031||Collagen skin test|
|HCPCS codes not covered for indications listed in the CPB:|
|L8603||Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies|
|ICD-10 codes covered if selection criteria are met:|
|N13.70 - N13.9||Vesicoureteral-reflux|
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
HCPCS
|
CMS is considering phasing out HCPCS. There are 3 levels within HCPCS:
HCPCS Level 1
Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
HCPCS
|
There are 3 levels within HCPCS:
HCPCS Level 1
Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
HCPCS
|
HCPCS Level 2
Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. Current Procedural Terminology (CPT) is an outpatient medical coding codeset that is copy-written by the American Medical Association.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
HCPCS
|
HCPCS Level 3
Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. Current Procedural Terminology (CPT) is an outpatient medical coding codeset that is copy-written by the American Medical Association. Despite CPT's widespread use, you have to pay high licensing fees to use the CPT codeset.
|
31254
|
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31294
|
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
61548
|
Removal of pituitary gland
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31288
|
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
G0340
|
Robt lin-radsurg fractx 2-5
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31287
|
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
G0339
|
Robot lin-radsurg com, first
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31276
|
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
S8030
|
Tantalum ring application
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31290
|
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31256
|
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31267
|
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
61795
|
Brain surgery using computer
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated.
|
31254
|
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31294
|
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
61548
|
Removal of pituitary gland
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31288
|
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
G0340
|
Robt lin-radsurg fractx 2-5
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31287
|
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
G0339
|
Robot lin-radsurg com, first
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31276
|
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
S8030
|
Tantalum ring application
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31290
|
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31256
|
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31267
|
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
61795
|
Brain surgery using computer
|
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated.
|
31254
|
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31294
|
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
61548
|
Removal of pituitary gland
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31288
|
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
1996
|
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
G0340
|
Robt lin-radsurg fractx 2-5
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31287
|
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
G0339
|
Robot lin-radsurg com, first
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31276
|
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
S8030
|
Tantalum ring application
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31290
|
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31256
|
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31267
|
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
61795
|
Brain surgery using computer
|
HCPCS
|
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted.
|
31254
|
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31294
|
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
61548
|
Removal of pituitary gland
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31288
|
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
G0340
|
Robt lin-radsurg fractx 2-5
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31287
|
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
G0339
|
Robot lin-radsurg com, first
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31276
|
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
S8030
|
Tantalum ring application
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31290
|
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
31256
|
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
|
HCPCS
|
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
|
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