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J1212
|
Injection, dmso, dimethyl sulfoxide, 50%, 50 ml
|
HCPCS
|
The use of lidocaine or other local analgesic is also not usually reported separately. Besides CPT code 51700 for the bladder instillation, you will also need to report the code for the drug instilled. For example, if the documentation indicates that 50 ml of dimethyl sulfoxide (DMSO) 50% aqueous irrigation solution was instilled into the bladder, the appropriate HCPCS code would be:
J1212 – Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
According to United Healthcare’s Policy Guideline, coverage of DMSO will depend on the individual insurance plan and what is reasonable and necessary. DMSO may not be considered reasonable and necessary for treatment of another condition other than interstitial cystitis. Hopefully, you now have a better understanding of interstitial cystitis and how it is diagnosed and treated.
|
51700
|
Simple bladder irrigation and/or instillation
|
HCPCS
|
The use of lidocaine or other local analgesic is also not usually reported separately. Besides CPT code 51700 for the bladder instillation, you will also need to report the code for the drug instilled. For example, if the documentation indicates that 50 ml of dimethyl sulfoxide (DMSO) 50% aqueous irrigation solution was instilled into the bladder, the appropriate HCPCS code would be:
J1212 – Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml
According to United Healthcare’s Policy Guideline, coverage of DMSO will depend on the individual insurance plan and what is reasonable and necessary. DMSO may not be considered reasonable and necessary for treatment of another condition other than interstitial cystitis. Hopefully, you now have a better understanding of interstitial cystitis and how it is diagnosed and treated.
|
00811
|
ANES LWR INTST NDSC NOS
|
CPT
|
These codes are organized into six sections as follows:
1. Evaluation and Management:
This section includes codes for services provided by healthcare professionals, such as consultations, office visits, hospital visits and stays, and preventive medicine services to evaluate, diagnose and manage patients. E&M codes start from 99-series of CPT codes, i.e., 99213, 99214, etc
This section includes codes for anesthesia services, such as the type of anesthesia used, the patient’s physical status during the procedure, and the duration of anesthesia provided during surgical or diagnostic procedures. Anesthesia codes are unique that begin with the digit “zero.” For example, 00811, 00720, etc. This section includes the codes assigned to major and minor surgical procedures.
|
00811
|
ANES LWR INTST NDSC NOS
|
CPT
|
Evaluation and Management:
This section includes codes for services provided by healthcare professionals, such as consultations, office visits, hospital visits and stays, and preventive medicine services to evaluate, diagnose and manage patients. E&M codes start from 99-series of CPT codes, i.e., 99213, 99214, etc
This section includes codes for anesthesia services, such as the type of anesthesia used, the patient’s physical status during the procedure, and the duration of anesthesia provided during surgical or diagnostic procedures. Anesthesia codes are unique that begin with the digit “zero.” For example, 00811, 00720, etc. This section includes the codes assigned to major and minor surgical procedures. These codes describe the extent of the procedure, the surgical approach used, and any additional procedures provided.
|
90739
|
HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSY
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90746
|
Hepb vaccine 3 dose adult im
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90743
|
HC HEPB VACCINE ADOLESCENT 2 DOSE SCHEDULE IM
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
G0010
|
PR ADMIN HEPATITIS B VACCINE
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90744
|
Hepb vacc 3 dose ped/adol im
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90747
|
HC HEPB VACCINE DIALYSIS/IMMUNSUP PAT 4 DOSE IM
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90740
|
Hepb vacc 3 dose immunsup im
|
HCPCS
|
The infection can last as little as a few weeks or become a lifelong, debilitating illness. There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs.
|
90739
|
HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSY
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
90746
|
Hepb vaccine 3 dose adult im
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
90743
|
HC HEPB VACCINE ADOLESCENT 2 DOSE SCHEDULE IM
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
G0010
|
PR ADMIN HEPATITIS B VACCINE
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
90744
|
Hepb vacc 3 dose ped/adol im
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
90747
|
HC HEPB VACCINE DIALYSIS/IMMUNSUP PAT 4 DOSE IM
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
90740
|
Hepb vacc 3 dose immunsup im
|
HCPCS
|
There is no vaccine for Hepatitis C.
Coding and Billing Guidelines
Medicare Part B provides payment for Hepatitis B vaccine and its administration, as well as for screening for sexually transmitted infections (STIs) and Hepatitis C, and high-intensity behavioral counseling to prevent STIs. CPT® vaccination codes:
90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
When billing Medicare Part B, vaccine administration code is HCPCS Level II G0010 Administration of hepatitis b vaccine. Be sure to link diagnosis code ICD-9-CM V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis (ICD-10 Z23 Encounter for immunization) to the procedure code. Because Hepatitis vaccine is a preventive service, eligible beneficiaries may receive these services with no out-of-pocket costs. For conditions of coverage, refer to Medicare National Coverage Determinations Manual Chapter 1, Part 4, section 210.10 – Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.
|
33246
|
Insert epic eltrd/generator
|
HCPCS
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
G0300
|
Hhs/hospice of lpn ea 15 min
|
HCPCS
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
33245
|
Insert epic eltrd pace-defib
|
HCPCS
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
G0299
|
Hhs/hospice of rn ea 15 min
|
HCPCS
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
G0297
|
LOW-DOSE CT SCAN (LDCT) FOR LUNG CANCER SCREENING
|
HCPCS
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
G0298
|
Insert dual chamber/cd
|
CPT
|
The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Rationale and references were updated. Coding section was updated with 01/01/08 CPT/HCPCS changes; removed HCPCS G0297, G0298, G0299, G0300 deleted 12/31/2007.|
|Reviewed||03/08/2007||MPTAC review. Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review.
|
33245
|
Insert epic eltrd pace-defib
|
HCPCS
|
Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organization||Last Review Date||Document Number||Title|
|09/19/2003||SURG.00033||Automatic Implantable Cardioverter-Defibrillator (AICD), Cardiac Resynchronization Therapy Defibrillator (CRT-D), Biventricular Pacemakers|
|WellPoint Health Networks, Inc||06/24/2004||9.04.03||Implantable Cardioverter-defibrillators|
|
33246
|
Insert epic eltrd/generator
|
HCPCS
|
Rationale, References, and Coding sections have been updated.|
|01/01/2007||Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 33245, 33246 deleted 12/31/2006.|
|Reviewed||03/23/2006||MPTAC review. References were updated to include the recently released updated TEC Assessment Directories (2) and additional published articles.|
|11/18/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||04/28/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organization||Last Review Date||Document Number||Title|
|09/19/2003||SURG.00033||Automatic Implantable Cardioverter-Defibrillator (AICD), Cardiac Resynchronization Therapy Defibrillator (CRT-D), Biventricular Pacemakers|
|WellPoint Health Networks, Inc||06/24/2004||9.04.03||Implantable Cardioverter-defibrillators|
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT).
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
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 # 8.01.29 per approval by Medical Policy Advisory Committee (MPAC)
7/14/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC, no changes
7/14/2005: Code Reference section updated, CPT code 38230 added covered codes, HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added covered codes, HCPCS J9000-J9999 statement added to HCPCS and all separately listed codes deleted
10/26/2005: Code Reference section updated, ICD-9 procedure codes 41.01, 41.02, 41.03, 41.09 added
3/14/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
5/21/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
Supporting explanations added to the policy guidelines. FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
Supporting explanations added to the policy guidelines. FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
Supporting explanations added to the policy guidelines. FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
Supporting explanations added to the policy guidelines. FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.
|
86825
|
X-MATCHAHG
|
HCPCS
|
Supporting explanations added to the policy guidelines. FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes.
|
86825
|
X-MATCHAHG
|
HCPCS
|
FEP and State and School Employee 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes. 03/13/2013: 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes. 03/13/2013: 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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes. 03/13/2013: Policy reviewed; no changes.
|
G0266
|
Thawing + expansion froz cel
|
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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes. 03/13/2013: Policy reviewed; no changes.
|
86825
|
X-MATCHAHG
|
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. 12/28/2010: Added policy statement regarding when tandem autologous HSCT may be considered medically necessary. 01/17/2012: Policy reviewed; no changes. 03/13/2013: Policy reviewed; no changes.
|
38241
|
Transplt autol hct/donor
|
HCPCS
|
03/13/2013: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes. 01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
03/13/2013: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes. 01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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.
|
38240
|
Transplt allo hct/donor
|
HCPCS
|
03/13/2013: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes. 01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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.
|
96445
|
Chemotherapy, intracavitary
|
HCPCS
|
03/13/2013: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes. 01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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.
|
96446
|
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
|
HCPCS
|
03/13/2013: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes. 01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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.
|
38241
|
Transplt autol hct/donor
|
HCPCS
|
01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged.
|
38240
|
Transplt allo hct/donor
|
HCPCS
|
01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged.
|
96445
|
Chemotherapy, intracavitary
|
HCPCS
|
01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged.
|
96446
|
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
|
HCPCS
|
01/29/2015: Policy description updated regarding the estimated number of cases for Hodgkin Lymphoma and to change "radiation therapy" to "radiotherapy." Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged.
|
38241
|
Transplt autol hct/donor
|
HCPCS
|
Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
|
38240
|
Transplt allo hct/donor
|
HCPCS
|
Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
|
96445
|
Chemotherapy, intracavitary
|
HCPCS
|
Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
|
96446
|
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
|
HCPCS
|
Investigational policy statements updated to change "stem-cell transplantation" to "hematopoietic stem-cell transplantation." 08/27/2015: 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. 03/23/2016: Policy description updated regarding FDA regulations. Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions.
|
30230Y3
|
TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
0243
|
All Inclusive Ancillary - Specialty
|
RC
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30240Y3
|
TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30230G3
|
TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30230Y2
|
TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
0230
|
Incremental Nursing Charge - General Classification
|
RC
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30233Y3
|
TRANSFUSION OF ALLOGENEIC UNRELATED HAMATOPOIETIC STEM CELLS INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30243G3
|
TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30230G2
|
TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO PERIPHERAL VEIN, OPEN APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30240G2
|
TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30243Y2
|
TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
0233
|
Incremental Nursing Charge - ICU
|
RC
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30243G2
|
TRANSFUSION OF ALLOGENEIC RELATED BONE MARROW INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30243Y3
|
TRANSFUSION OF ALLOGENEIC UNRELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30240Y2
|
TRANSFUSION OF ALLOGENEIC RELATED HEMATOPOIETIC STEM CELLS INTO CENTRAL VEIN, OPEN APPROACH Reduced Intensity Medsurg
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30233G3
|
TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO PERIPHERAL VEIN, PERCUTANEOUS APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
0240
|
HC BH RESIDENTIAL FULL MONTH STAY
|
RC
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
30240G3
|
TRANSFUSION OF ALLOGENEIC UNRELATED BONE MARROW INTO CENTRAL VEIN, OPEN APPROACH Tandem Autologous Allogeneic Unrelated Non ICU
|
ICD
|
Policy statements unchanged. Policy guidelines updated to add medically necessary and investigative definitions. 05/26/2016: Policy number added. 09/30/2016: Code Reference section updated to add the following new ICD-10 procedure codes: 30230G2, 30233G2, 30240G2, 30243G2, 30230G3, 30233G3, 30240G3, 30243G3, 30230G4, 30233G4, 30240G4, 30243G4, 30230Y2, 30233Y2, 30240Y2, 30243Y2, 30230Y3, 30233Y3, 30240Y3, 30243Y3, 30230Y4, 30233Y4, 30240Y4, and 30243Y4. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.29
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
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