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|---|---|---|---|
G6011
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6007
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
77407
|
HC RADIATION TREATMENT DELIVERY
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6012
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6009
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6013
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6008
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
77412
|
RAD TRMT DELIVERY, > 1 MEV, COMPL
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6010
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6014
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6004
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
61795
|
Brain surgery using computer
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
|
G6011
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6007
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
77407
|
HC RADIATION TREATMENT DELIVERY
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6012
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6009
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6013
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6008
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
77412
|
RAD TRMT DELIVERY, > 1 MEV, COMPL
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6010
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6014
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6004
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
61795
|
Brain surgery using computer
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3. 12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes.
|
G6011
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6007
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
77407
|
HC RADIATION TREATMENT DELIVERY
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6012
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6009
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6013
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6008
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
77412
|
RAD TRMT DELIVERY, > 1 MEV, COMPL
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6010
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6014
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6004
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma. 12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added.
|
G6011
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6007
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
77407
|
HC RADIATION TREATMENT DELIVERY
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6012
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6009
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6013
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6008
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
77412
|
RAD TRMT DELIVERY, > 1 MEV, COMPL
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
77402
|
HC RAD TX> 1MEV, SIMPLE
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6010
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6014
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6004
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
|
G6011
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6007
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6012
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6003
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6005
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6009
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6013
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6008
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6010
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6014
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6004
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G6006
|
Radiation treatment delivery
|
HCPCS
|
Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014. 08/27/2015: Code Reference section updated to add ICD-10 codes. 06/07/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)Hayes Medical Technology Directory
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
This may not be a comprehensive list of procedure codes applicable to this policy.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38214
|
Volume deplete of harvest
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38209
|
Wash harvest stem cells
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38204
|
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38213
|
PR TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38215
|
PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38211
|
Tumor cell deplete of harvst
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38207
|
PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38208
|
Thaw preserved stem cells
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38210
|
T-cell depletion of harvest
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38212
|
Rbc depletion of harvest
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
38205
|
PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated.
|
38214
|
Volume deplete of harvest
|
HCPCS
|
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22
8/19/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230 added; ICD-9 Procedures 41.02, 41.03, 41.05, 41.08 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
03/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 09/12/2006: Coding updated. ICD9 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
9/18/2007: Code reference section updated.
|
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