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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.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86816
|
HC HLA TYPING DR/DQ SINGLE AG
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
38204
|
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86821
|
Lymphocyte culture mixed
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86812
|
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86822
|
Lymphocyte culture primed
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86817
|
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
86813
|
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86816
|
HC HLA TYPING DR/DQ SINGLE AG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
38204
|
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86821
|
Lymphocyte culture mixed
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86812
|
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86822
|
Lymphocyte culture primed
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86817
|
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
86813
|
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
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. 3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes.
|
G0358
|
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86816
|
HC HLA TYPING DR/DQ SINGLE AG
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0360
|
Each additional hr 1-8 hrs
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
38204
|
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86821
|
Lymphocyte culture mixed
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
J9999
|
Not otherwise classified, antineoplastic drugs
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0361
|
Prolong chemo infuse>8hrs pu
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86812
|
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86822
|
Lymphocyte culture primed
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0359
|
Chemotherapy IV one hr initi
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
38230
|
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86817
|
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0363
|
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
J9000
|
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0364
|
HC BONE MARROW ASPIRATE & BIOPSY
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0362
|
Each add sequential infusion
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86813
|
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0357
|
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0356
|
HORMONAL ANTINEOPLASTIC
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
G0355
|
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
|
HCPCS
|
3/25/2004: 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 # 8.01.27 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/27/2005: Code Reference section updated; Covered table - CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted; Non-Covered table - CPT-4 code 38204, 86812, 86813, 86816, 86817, 86821, 86822 added, ICD-9 Procedure 41.02, 41.03 added
3/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
1/3/2007: Policy reviewed, all medically necessary language removed as newer studies have shown no increase survival of patients with stem cell transplants after high-dose chemotherapy
1/4/2007: Code reference section updated; All CPT, HCPCS, and ICD-9 procedure codes moved to non-covered. Covered codes removed
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
1/06/2009: Policy reviewed. No changes. 4/20/2010: High Dose Chemotherapy deleted from title.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007.
|
86825
|
X-MATCHAHG
|
HCPCS
|
Policy description updated to include detailed description of Hematopoietic Stem Cell Transplantation (HSCT). Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes.
|
86825
|
X-MATCHAHG
|
HCPCS
|
Policy statement updated to include Single or Tandem autologous hematopoietic stem-cell transplant is considered not medically necessary to treat any stage of breast cancer. High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes.
|
86826
|
Hla x-match noncytotoxc addl
|
HCPCS
|
High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes.
|
G0267
|
Bone marrow or psc harvest
|
CPT
|
High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes.
|
G0265
|
Cryopresevation Freeze+stora
|
CPT
|
High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes.
|
G0266
|
Thawing + expansion froz cel
|
CPT
|
High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes.
|
86825
|
X-MATCHAHG
|
HCPCS
|
High Dose Chemotherapy language deleted from policy statement section. CPT code reference section update: New CPT codes 86825 and 86826 added to noncovered table. HCPCS codes G0265, G0266 and G0267 deleted from non-covered table due to these codes were deleted codes as of 12-31-2007. 04/19/2011: Policy reviewed; no changes. 03/02/2012: Policy reviewed; no changes.
|
E0751
|
PULSE GENERATOR OR RECEIVER
|
CPT
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
95972
|
PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
63690
|
-1
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
95970
|
PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
E0753
|
NEUROSTIMUL ELECTRODES/LEADS
|
CPT
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
95971
|
PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
63685
|
PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
63691
|
-1
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
E0754
|
PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN
|
CPT
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
E0752
|
IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH
|
CPT
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
63660
|
Revise/Remove Neuroelectrode
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
95973
|
Analyze neurostim complex
|
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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement.
|
E0751
|
PULSE GENERATOR OR RECEIVER
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
95972
|
PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
63690
|
-1
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
1999
|
ANESTHESIOLOGY GROUP
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
95970
|
PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
E0753
|
NEUROSTIMUL ELECTRODES/LEADS
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
95971
|
PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
63685
|
PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
|
63691
|
-1
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines.
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