Split (1)

train · 15.7k rows

code stringlengths 4 12	description stringlengths 2 264	codetype stringclasses 8 values	context stringlengths 160 15.5k
38209	Wash harvest stem cells	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.
G0360	Each additional hr 1-8 hrs	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.
38204	PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ	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.
38213	PR TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ	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.
38215	PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM	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.
J9999	Not otherwise classified, antineoplastic drugs	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.
G0361	Prolong chemo infuse>8hrs pu	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.
38211	Tumor cell deplete of harvst	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.
38207	PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR	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.
38208	Thaw preserved stem cells	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.
G0359	Chemotherapy IV one hr initi	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.
38210	T-cell depletion 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.
38230	PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC	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.
38212	Rbc depletion 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.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	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.
J9000	INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG	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.
G0364	HC BONE MARROW ASPIRATE & BIOPSY	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.
38205	PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC	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.
G0362	Each add sequential infusion	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.
G0357	IV PUSH TECHNIQUE SINGLE/INIT 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.
G0356	HORMONAL ANTINEOPLASTIC	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.
G0355	CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC	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.
G0358	IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38214	Volume deplete of harvest	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38209	Wash harvest stem cells	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0360	Each additional hr 1-8 hrs	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38204	PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38213	PR TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38215	PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
J9999	Not otherwise classified, antineoplastic drugs	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0361	Prolong chemo infuse>8hrs pu	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38211	Tumor cell deplete of harvst	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38207	PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38208	Thaw preserved stem cells	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0359	Chemotherapy IV one hr initi	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38210	T-cell depletion of harvest	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38230	PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38212	Rbc depletion of harvest	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0363	IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
J9000	INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0364	HC BONE MARROW ASPIRATE & BIOPSY	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
38205	PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0362	Each add sequential infusion	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0357	IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0356	HORMONAL ANTINEOPLASTIC	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0355	CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC	HCPCS	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. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated.
G0267	Bone marrow or psc harvest	CPT	ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007.
G0266	Thawing + expansion froz cel	CPT	ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007.
G0265	Cryopresevation Freeze+stora	CPT	ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007.
G0267	Bone marrow or psc harvest	CPT	ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias.
G0266	Thawing + expansion froz cel	CPT	ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias.
G0265	Cryopresevation Freeze+stora	CPT	ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-31-2007. 06/04/2010: The title changed from “High Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias” to “Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias.” Policy description was revised to include detailed information regarding genetic diseases and acquired anemias.
30233G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30243Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
0233	Incremental Nursing Charge - ICU	RC	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30233Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30243G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30233G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30233Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
0243	All Inclusive Ancillary - Specialty	RC	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30243Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30243G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Policy guidelines section updated to add guidelines for primary immunodeficiencies and inherited metabolic disease. Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
30233G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
0233	Incremental Nursing Charge - ICU	RC	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
0243	All Inclusive Ancillary - Specialty	RC	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	Added medically necessary definition. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
0233	Incremental Nursing Charge - ICU	RC	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233G2	TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30233Y2	TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
0243	All Inclusive Ancillary - Specialty	RC	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243Y3	TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
30243G3	TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU	ICD	09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30233G2, 30233G3, 30233G4, 30233Y2, 30233Y3, 30233Y4, 30243G2, 30243G3, 30243Y2, 30243Y3, and 30243Y4. Added new ICD-10 diagnosis code D47.Z2. SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.22 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
G0281	PR ELEC STIM UNATTEND FOR PRESS	HCPCS	Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
G0282	HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE	HCPCS	Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
G0329	PR ELECTROMAGNTIC TX FOR ULCERS	HCPCS	Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
G0295	Electromagnetic therapy onc	HCPCS	Electrical stimulation performed by the patient in the home setting for the treatment of wounds is considered investigational. Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
G0281	PR ELEC STIM UNATTEND FOR PRESS	HCPCS	Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
G0282	HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE	HCPCS	Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
G0329	PR ELECTROMAGNTIC TX FOR ULCERS	HCPCS	Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
G0295	Electromagnetic therapy onc	HCPCS	Electromagnetic therapy for the treatment of wounds is considered investigational. The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
E0761	Nontherm electromgntc device	HCPCS	The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device.
G0282	HC ELECTRICAL STIMULATION, TO ONE OR MORE AREAS, FOR WOUND CARE	HCPCS	The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device.
G0329	PR ELECTROMAGNTIC TX FOR ULCERS	HCPCS	The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device.
G0295	Electromagnetic therapy onc	HCPCS	The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device.
G0281	PR ELEC STIM UNATTEND FOR PRESS	HCPCS	The following HCPCS codes are available for this treatment: G0281: Electrical stimulation (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care. G0282: Electrical stimulation (unattended), to one or more areas, for wound care other than described in G0281. G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device.
E0761	Nontherm electromgntc device	HCPCS	G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation.
G0329	PR ELECTROMAGNTIC TX FOR ULCERS	HCPCS	G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation.
G0295	Electromagnetic therapy onc	HCPCS	G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation.
E0769	Electric wound treatment dev	HCPCS	G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation.
G0281	PR ELEC STIM UNATTEND FOR PRESS	HCPCS	G0295: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. G0329: Electromagnetic therapy, to one or more areas, for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care. E0761: Non-thermal pulsed high-frequency radiowaves, high peak power electromagnetic energy treatment device. E0769: Electrical stimulation or electromagnetic wound treatment device, not otherwise classified. The HCPCS code G0281 (unattended electrical stimulation) was specifically developed to make a distinction between attended and unattended electrical stimulation.

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