code
stringlengths 4
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stringlengths 2
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stringclasses 8
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stringlengths 160
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|---|---|---|---|
43633
|
Removal of stomach partial
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43847
|
PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43846
|
PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43645
|
PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
S2085
|
Laparoscop gastric bypass
|
CPT
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43848
|
Revision gastroplasty
|
HCPCS
|
2/1/2002: Mid-Delta Home Health added to POLICY EXCEPTIONS
2/13/2002: Investigational definition added
3/8/2002: Prior authorization deleted. Policy Exceptions are Group Specific, Renal Care Group added to POLICY EXCEPTIONS
5/1/2002: Type of Service and Place of Service deleted
6/3/2002: CPT code 43848 moved to covered
10/8/2002: Laparoscopic and other investigational procedures added to Surgical Management, Chevron/Texaco POLICY EXCEPTIONS added, Sources updated, Code Reference section updated
3/3/2003: CPT code 43659 updated
9/22/2003: FEP Policy Exception added, Biliopancreatic Bypass with Duodenal Switch added to CPT 43659, Biliopancreatic Bypass moved from CPT 43659 to CPT 43857
11/2003: Reviewed by MPAC, no changes
2/27/2004: Code Reference section updated
4/22/2004: CPT code 43633 added
8/18/2004: Policy Exception for Singing River “Note: Singing River (self-insured group) effective 9/1/2004, there will be a $10,000 per lifetime limit on surgical treatment for morbid obesity and any resulting complications of such surgery. All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated.
|
43644
|
PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
S2083
|
PR ADJUSTMENT GASTRIC BAND
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
S2082
|
Lap adjustable gastric band
|
CPT
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
43659
|
HC UNLISTED LAPAROSCOPE PROC STOM
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
43846
|
PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
43847
|
PR GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
43645
|
PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
S2085
|
Laparoscop gastric bypass
|
CPT
|
All surgical procedures must be prior authorized and all BCBSMS policy requirements under 'Surgical Management' section in effect at the time of the surgical procedure must be satisfied for coverage.” added
10/21/2004: Metropolitan Life Height and Weight Tables added
11/18/2004: Reviewed by MPAC, no changes, Sources updated
1/5/2005: Short limb < 100 cm changed to 150 cm or less, Code Reference section updated, CPT 43644 added covered codes, CPT 43659 note added, CPT 43846 description revised, ICD-9 procedure code 44.68, 44.96 added covered codes, HCPCS S2085 deletion date of 12/31/2004 added, CPT 43645, 43845 added non-covered codes, CPT 43659 note added non-covered codes, CPT 43847 description revised and note added, ICD-9 procedure code 44.93, 44.94, 44.95, 44.97, 44.98, 44.99, 97.86 added non-covered codes, HCPCS S2082, S2083 added non-covered codes
2/8/2005: Singing River clarification "Only the surgical procedures listed under 'Surgical Management' section as identified by 'eligible for coverage' are covered. Those procedures/surgeries that are listed as 'investigational' are not covered regardless of medical necessity." added
11/8/2005: Code Reference Section updated, ICD9 diagnosis codes V85.23-V85.25, V85.30-V85.39, V85.4 added
2/2/2006: Policy Exception section updated, prior authorization requirement was removed from BancorpSouth
3/15/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
6/13/2006: Policy updated. Singing River ( a self-funded group) will cover Gastric Banding/Lap Band procedure effective 9/1/2004
8/28/2006: Policy updated.
|
S2083
|
PR ADJUSTMENT GASTRIC BAND
|
HCPCS
|
CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section.
|
43774
|
PR LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT
|
HCPCS
|
CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section.
|
43888
|
PR GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT
|
HCPCS
|
CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section.
|
43770
|
PR LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE
|
HCPCS
|
CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section.
|
43886
|
Revise gastric port open
|
HCPCS
|
CPT codes 43770-43774, 43886-43888, HCPCS code S2083, ICD-9 procedure codes 44.95, 44.97, 44.98 moved to covered
7/30/2010: Policy description updated to include detailed descriptions of gastric restrictive procedures and malabsorptive procedures. Policy statement section updated to include open or laparoscopic biliopancreatic bypass (the Scopinaro procedure) with duodenal switch may be medically necessary, biliopancreatic bypass without duodenal switch, bariatric surgery as a cure for type 2 diabetes mellitus and endoscopic procedures are considered investigational. Policy exception section updated to include gastric sleeve coverage effective 5-1-2010 for Singing River and Mid Delta Home Health coverage language deleted. FEP Service Benefit plan language deleted. FEP prior authorization requirement and FDA language added to policy exception section.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit.
|
S9452
|
Nutrition class
|
HCPCS
|
FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit.
|
43659
|
HC UNLISTED LAPAROSCOPE PROC STOM
|
HCPCS
|
FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit.
|
43846
|
PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<
|
HCPCS
|
FEP prior authorization requirement and FDA language added to policy exception section. Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table.
|
S9452
|
Nutrition class
|
HCPCS
|
Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table.
|
43659
|
HC UNLISTED LAPAROSCOPE PROC STOM
|
HCPCS
|
Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table.
|
43846
|
PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<
|
HCPCS
|
Policy guidelines section updated to include detailed information regarding patient selection criteria and BMI calculation. Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21.
|
S9452
|
Nutrition class
|
HCPCS
|
Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21.
|
43659
|
HC UNLISTED LAPAROSCOPE PROC STOM
|
HCPCS
|
Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21.
|
43846
|
PR GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/<
|
HCPCS
|
Code reference section updated: Description revised for CPT codes 43659 and 43846. CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21.
|
43845
|
PR GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM
|
HCPCS
|
CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21. Re-formatted the information in the policy statement regarding surgical procedures; intent unchanged.
|
S9452
|
Nutrition class
|
HCPCS
|
CPT code 43845 added to covered table, ICD-9 diagnosis code 997.4 added to covered table, HCPCS code S9452 added to covered table. 10/19/2010: Annual ICD-9 code update: V85.4 deleted/expanded to the fifth digit. Added V85.41-V85.45 to the Covered Codes table. 08/19/2011: Policy statement revised to state that the patient must be at least 18 years of age instead of 21. Re-formatted the information in the policy statement regarding surgical procedures; intent unchanged.
|
G6015
|
Radiation tx delivery imrt
|
HCPCS
|
Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
77386
|
HC IMRT COMPLEX
|
HCPCS
|
Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
77385
|
HC IMRT SIMPLE
|
HCPCS
|
Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
G6016
|
PR DELIVERY COMP IMRT
|
HCPCS
|
Policy description and statement updated to change "radiation therapy" to "radiotherapy." Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
G6015
|
Radiation tx delivery imrt
|
HCPCS
|
Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements.
|
77386
|
HC IMRT COMPLEX
|
HCPCS
|
Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements.
|
77385
|
HC IMRT SIMPLE
|
HCPCS
|
Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements.
|
G6016
|
PR DELIVERY COMP IMRT
|
HCPCS
|
Added policy statement: Intensity-modulated radiotherapy (IMRT) is considered not medically necessary for the treatment of tumors of the CNS for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements.
|
G6015
|
Radiation tx delivery imrt
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
77386
|
HC IMRT COMPLEX
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
77385
|
HC IMRT SIMPLE
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
G6016
|
PR DELIVERY COMP IMRT
|
HCPCS
|
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions.
|
G6015
|
Radiation tx delivery imrt
|
HCPCS
|
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. SOURCE(S)Blue Cross Blue Shield Association policy #8.01.59
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
G6016
|
PR DELIVERY COMP IMRT
|
HCPCS
|
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy reviewed; no change in policy statements. Policy Guidelines section updated to add medically necessary and investigative definitions. SOURCE(S)Blue Cross Blue Shield Association policy #8.01.59
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
|
20987
|
Cptr-asst dir ms px pre img
|
CPT
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/17/2008: Policy added
12/29/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
6/23/2010: Description section revised. FEP verbiage was added to Policy Exceptions section. Code Reference section revised to remove CPT Codes 20986 and 20987 because the codes were deleted 12/31/2008.
|
20986
|
Cptr-asst dir ms px io img
|
CPT
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/17/2008: Policy added
12/29/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
6/23/2010: Description section revised. FEP verbiage was added to Policy Exceptions section. Code Reference section revised to remove CPT Codes 20986 and 20987 because the codes were deleted 12/31/2008.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
POLICY HISTORY8/24/2007: Policy added
9/19/2007: Code reference section updated. ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
ICD-9 2007 revisions added to policy
11/15/2007: Policy approved by MPAC
10/7/2008: Policy reviewed, no changes
3/15/2010: Code Reference section updated. New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement.
|
L8692
|
Non-osseointegrated snd proc
|
HCPCS
|
New HCPCS code L8692 added to covered table. 04/21/2010: Policy description updated regarding FDA approval of devices. The medically necessary policy statements were revised to add “5 years of age and older” to be consistent with FDA-approved labeling. “Sensorineural” added to the second statement. The intent of the policy statements unchanged.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
The intent of the policy statements unchanged. FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
FEP verbiage added to the Policy Exceptions section. 03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged.
|
L8693
|
IMPL COCLR 4MM BAHA TI ABTMNT B1300
|
HCPCS
|
03/09/2011: Added new HCPCS code L8693 to the Code Reference section. 04/25/2011: Audiologic criteria moved from the policy guidelines to the policy statement. 03/02/2012: Added policy statement to indicate that partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission are considered investigational. Other policy statements unchanged. 04/04/2013: Policy reviewed; no changes.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged.
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: 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
|
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 # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
S2140
|
Cord blood harvesting for transplantation, allogeneic
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section.
|
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