code
stringlengths 4
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stringclasses 8
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stringlengths 160
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|---|---|---|---|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.34 per approval by Medical Policy Advisory Committee (MPAC)
7/1/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/28/2005: Code Reference section updated; CPT-4 code 38230 added, ICD-9 procedure codes 41.01,41.02, 41.03, 41.09 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/16/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors. Policy statement revised to indicate that multiple cycle high-dose chemotherapy and hematopoietic stem-cell support (i.e., tandem or multiple transplants) is considered investigational for treatment of neuroblastoma.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors. Policy statement revised to indicate that multiple cycle high-dose chemotherapy and hematopoietic stem-cell support (i.e., tandem or multiple transplants) is considered investigational for treatment of neuroblastoma.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/9/2008: Policy reviewed, no changes
10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.73 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted as of 12-21-2007. 04/26/2010: Policy title and statement revised to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated with recent literature regarding solid tumors. Policy statement revised to indicate that multiple cycle high-dose chemotherapy and hematopoietic stem-cell support (i.e., tandem or multiple transplants) is considered investigational for treatment of neuroblastoma.
|
38241
|
Transplt autol hct/donor
|
HCPCS
|
Policy statement on salvage allogeneic hematopoietic stem-cell transplantation revised to remove "neuroblastoma or other" from the policy statement. It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
Policy statement on salvage allogeneic hematopoietic stem-cell transplantation revised to remove "neuroblastoma or other" from the policy statement. It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged.
|
38240
|
Transplt allo hct/donor
|
HCPCS
|
Policy statement on salvage allogeneic hematopoietic stem-cell transplantation revised to remove "neuroblastoma or other" from the policy statement. It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged.
|
96445
|
Chemotherapy, intracavitary
|
HCPCS
|
Policy statement on salvage allogeneic hematopoietic stem-cell transplantation revised to remove "neuroblastoma or other" from the policy statement. It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged.
|
96446
|
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
|
HCPCS
|
Policy statement on salvage allogeneic hematopoietic stem-cell transplantation revised to remove "neuroblastoma or other" from the policy statement. It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged.
|
38241
|
Transplt autol hct/donor
|
HCPCS
|
It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
38240
|
Transplt allo hct/donor
|
HCPCS
|
It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
96445
|
Chemotherapy, intracavitary
|
HCPCS
|
It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
96446
|
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
|
HCPCS
|
It previously stated: Salvage allogeneic hematopoietic stem-cell transplantation for neuroblastoma or other pediatric solid tumors that relapse after autologous transplant or fail to respond is considered investigational. 08/26/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240 and 38241; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 09/15/2015: Policy description updated regarding immunologic compatibility. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
93740
|
Temperature gradient studies
|
HCPCS
|
The authors concluded that static and dynamic IRT is a promising, objective method for intra-operative and post-operative monitoring of free-flap reconstructions in head and neck surgery and to detect perfusion failure, before macroscopic changes in the tissue surface are obvious. They noted that a lack of significant decrease of the temperature difference compared to surrounding tissue following completion of microvascular anastomoses and an atypical re-warming following a thermal challenge are suggestive of flap perfusion failure. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C00.0 - C96.9||Malignant neoplasms|
|E10.51 - E10.59
E11.51 - E11.59
|Diabetes mellitus with circulatory complications [Type 1 or 2]|
|I25.10 - I25.9||Coronary atherosclerosis|
|I73.9||Peripheral vascular disease, unspecified|
|M79.601 - M79.609||Pain in limb|
|M84.421S - M84.429S
M84.431S - M84.439S
S42.209S - S42.496S
S49.001S - S49.199S
S52.001S - S52.92xS
S59.001S - S59.299S
S62.90xS - S62.92xS
|Fracture of upper extremity, sequela|
|S52.501+ - S52.509+
S52.531+ - S52.539+
|Fracture of radius [open or closed]|
|Z01.810||Encounter for preprocedural cardiovascular examination|
|Z01.818||Encounter for other preprocedural examination|
|Z01.89||Encounter for other specified special examinations [not covered for intra-operative and post-operative perfusion assessment]|
|Z12.0 - Z12.9||Encounter for screening for malignant neoplasms|
|Z51.11 - Z51.12||Encounter for antineoplastic chemotherapy or immunotherapy|
|Z95.1||Presence of aortocoronary bypass graft|
|
93740
|
Temperature gradient studies
|
HCPCS
|
They noted that a lack of significant decrease of the temperature difference compared to surrounding tissue following completion of microvascular anastomoses and an atypical re-warming following a thermal challenge are suggestive of flap perfusion failure. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C00.0 - C96.9||Malignant neoplasms|
|E10.51 - E10.59
E11.51 - E11.59
|Diabetes mellitus with circulatory complications [Type 1 or 2]|
|I25.10 - I25.9||Coronary atherosclerosis|
|I73.9||Peripheral vascular disease, unspecified|
|M79.601 - M79.609||Pain in limb|
|M84.421S - M84.429S
M84.431S - M84.439S
S42.209S - S42.496S
S49.001S - S49.199S
S52.001S - S52.92xS
S59.001S - S59.299S
S62.90xS - S62.92xS
|Fracture of upper extremity, sequela|
|S52.501+ - S52.509+
S52.531+ - S52.539+
|Fracture of radius [open or closed]|
|Z01.810||Encounter for preprocedural cardiovascular examination|
|Z01.818||Encounter for other preprocedural examination|
|Z01.89||Encounter for other specified special examinations [not covered for intra-operative and post-operative perfusion assessment]|
|Z12.0 - Z12.9||Encounter for screening for malignant neoplasms|
|Z51.11 - Z51.12||Encounter for antineoplastic chemotherapy or immunotherapy|
|Z95.1||Presence of aortocoronary bypass graft|
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.23 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
10/26/2005: Code Reference section updated; CPT-4 code 38230 added; HCPCS code G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
12/21/2006: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/26/2010: Policy title updated to remove “High-Dose Chemotherapy” and to change “Stem-Cell Support” to “Stem-Cell Transplantation.” “High-dose chemotherapy” removed from policy statement; intent unchanged.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
S2140
|
Cord blood harvesting for transplantation, allogeneic
|
HCPCS
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
86825
|
X-MATCHAHG
|
HCPCS
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
S2142
|
Cord blood-derived stem-cell transplantation, allogeneic
|
HCPCS
|
Policy description updated regarding prevalence of disease and treatment approaches. FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
S2140
|
Cord blood harvesting for transplantation, allogeneic
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
86825
|
X-MATCHAHG
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
S2142
|
Cord blood-derived stem-cell transplantation, allogeneic
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes. 01/17/2012: Policy reviewed; no changes.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes. 01/17/2012: Policy reviewed; no changes.
|
S2140
|
Cord blood harvesting for transplantation, allogeneic
|
HCPCS
|
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes. 01/17/2012: Policy reviewed; no changes.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 12/28/2010: Policy reviewed; no changes. 01/17/2012: Policy reviewed; no changes.
|
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