code stringlengths 4 12 | description stringlengths 2 264 | codetype stringclasses 8 values | context stringlengths 160 15.5k |
|---|---|---|---|
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0267 | Bone marrow or psc harvest | CPT | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0265 | Cryopresevation Freeze+stora | CPT | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0266 | Thawing + expansion froz cel | CPT | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC)
7/13/2004: Code Reference section completed
7/1/2004: Reviewed by MPAC; The following changed from investigational to medically necessary: "High-dose chemotherapy with allogeneic stem cell support is may be medically necessary to treat AML relapsing after prior therapy with high-dose chemotherapy and autologous stem cell support." 10/27/2005: Code Reference section updated; CPT-4 code 38230 added; ICD-9 Procedure 41.01, 41.02, 41.03, 41.09 added; HCPCS G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added, J9000-J9999 deleted
3/22/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. |
86826 | Hla x-match noncytotoxc addl | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | CPT4/HCPCS revisions added to policy
5/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
S2140 | Cord blood harvesting for transplantation, allogeneic | HCPCS | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0265 | Cryopresevation Freeze+stora | CPT | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
G0266 | Thawing + expansion froz cel | CPT | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
S2142 | Cord blood-derived stem-cell transplantation, allogeneic | HCPCS | High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support
9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied
1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted
8/07/2009: Policy Description Section updated with definitions and descriptions for Conventional Preparative Conditioning for HSCT, Reduced-Intensity Conditioning for Allogeneic HSCT, and AML as well as WHO information and molecular studies information specific to AML, Policy Statement Section revised to add specific medically necessary criteria to the treatment of AML with Allogeneic HSCT using a myeloablative conditioning regimen, Allogeneic HSCT using a reduced-intensity conditioning regimen, and Autologous HSCT, Policy Guidelines updated to add AML with antecedent hematologic disease as a clinical feature that predicts poor outcomes of AML therapy, WHO classification of AML Risk Status table, candidate information, and donor information, Coding Section updated with a Note added to the CPT-4 Covered Codes Table, ICD-9 Procedure Code 41.00 added to Covered Table, HCPCS codes S2140 and S2142 added to covered table, removed deleted HCPCS codes G0265, G0266, G0267, and G0363 from Covered Table
04/26/2010: FEP and State and School Employee verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. 09/28/2011: Policy reviewed; no changes. 09/27/2012: Policy reviewed; no changes. 11/15/2013: Policy reviewed; no changes. |
00872 | ANESTH KIDNEY STONE DESTRUCT | CPT | POLICY HISTORY3/1993: ESWT for Gallstones approved by Medical Policy Advisory Committee (MPAC)
9/1994: ESWT for Kidney Stone approved by Medical Policy Advisory Committee (MPAC)
4/6/2001: Policy reviewed; Title changed to "ESWT", ESWT for kidney stones policy combined with ESWT for gallstones policy, ESWT for salivary and pancreatic stones added to the policy, Managed Care Requirements deleted, Policy History updated, Sources updated
8/2001: Reviewed by MPAC; ESWT considered investigational for Musculoskeletal conditions, including, but not limited to, plantar fasciitis, chronic plantar fasciitis, heel pain syndrome, epicondylitis, tendonopathies including calcific tendinitis of the shoulder, stress fracture, delayed union and nonunion, and gallstones. Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. |
0020T | XTRACORP SHOCK WAVE THERAPY-INVLV PLANTAR FASC | CPT | POLICY HISTORY3/1993: ESWT for Gallstones approved by Medical Policy Advisory Committee (MPAC)
9/1994: ESWT for Kidney Stone approved by Medical Policy Advisory Committee (MPAC)
4/6/2001: Policy reviewed; Title changed to "ESWT", ESWT for kidney stones policy combined with ESWT for gallstones policy, ESWT for salivary and pancreatic stones added to the policy, Managed Care Requirements deleted, Policy History updated, Sources updated
8/2001: Reviewed by MPAC; ESWT considered investigational for Musculoskeletal conditions, including, but not limited to, plantar fasciitis, chronic plantar fasciitis, heel pain syndrome, epicondylitis, tendonopathies including calcific tendinitis of the shoulder, stress fracture, delayed union and nonunion, and gallstones. Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. |
00873 | ANESTH KIDNEY STONE DESTRUCT | CPT | POLICY HISTORY3/1993: ESWT for Gallstones approved by Medical Policy Advisory Committee (MPAC)
9/1994: ESWT for Kidney Stone approved by Medical Policy Advisory Committee (MPAC)
4/6/2001: Policy reviewed; Title changed to "ESWT", ESWT for kidney stones policy combined with ESWT for gallstones policy, ESWT for salivary and pancreatic stones added to the policy, Managed Care Requirements deleted, Policy History updated, Sources updated
8/2001: Reviewed by MPAC; ESWT considered investigational for Musculoskeletal conditions, including, but not limited to, plantar fasciitis, chronic plantar fasciitis, heel pain syndrome, epicondylitis, tendonopathies including calcific tendinitis of the shoulder, stress fracture, delayed union and nonunion, and gallstones. Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. |
0020T | XTRACORP SHOCK WAVE THERAPY-INVLV PLANTAR FASC | CPT | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
00873 | ANESTH KIDNEY STONE DESTRUCT | CPT | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
00872 | ANESTH KIDNEY STONE DESTRUCT | CPT | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
28899 | HC UNLISTED PROCEDURE, FOOT OR TOES | HCPCS | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
48999 | HC UNLISTED PROCEDURE PANCREAS | HCPCS | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
52353 | PR CYSTO W/URETEROSCOPY W/LITHOTRIPSY | HCPCS | Policy exception - FEP subscribers only - for ESWT treatment of gallstones added. 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. |
0020T | XTRACORP SHOCK WAVE THERAPY-INVLV PLANTAR FASC | CPT | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
00873 | ANESTH KIDNEY STONE DESTRUCT | CPT | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
00872 | ANESTH KIDNEY STONE DESTRUCT | CPT | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
28899 | HC UNLISTED PROCEDURE, FOOT OR TOES | HCPCS | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
48999 | HC UNLISTED PROCEDURE PANCREAS | HCPCS | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
52353 | PR CYSTO W/URETEROSCOPY W/LITHOTRIPSY | HCPCS | 10/2/2001: New 2002 codes added
2/8/2002: Investigational definition added
4/22/2002: Type of Service and Place of Service deleted
5/7/2002: Code Reference section updated, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02. 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. |
0020T | XTRACORP SHOCK WAVE THERAPY-INVLV PLANTAR FASC | CPT | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
00873 | ANESTH KIDNEY STONE DESTRUCT | CPT | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
00872 | ANESTH KIDNEY STONE DESTRUCT | CPT | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
28899 | HC UNLISTED PROCEDURE, FOOT OR TOES | HCPCS | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
48999 | HC UNLISTED PROCEDURE PANCREAS | HCPCS | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
52353 | PR CYSTO W/URETEROSCOPY W/LITHOTRIPSY | HCPCS | 727.03, 727.04, 727.05, 726.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4 added to non-covered codes
5/2002: Reviewed by MPAC, ESWT criteria for kidney stones deleted, ESWT for chronic plantar fasciitis considered medically necessary as an alternative to surgery with certain criteria, Sources updated, CPT code 0020T moved to covered. 5/29/2002: ICD-9 diagnosis code 593.89 added
6/6/2002: Code Reference section updated
9/20/2002: Code Reference section updated
11/2002: Reviewed by MPAC; no changes
2/3/2003: Code Reference section updated
3/17/2003: Code Reference section updated
4/8/2003: Code Reference section updated, CPT codes 28899, 52353 deleted, ICD-9 diagnosis codes 593.4, 593.81, 593.89 deleted, ICD-9 diagnosis code 726.71, 726.72, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, moved from non-covered to covered codes, ICD-9 diagnosis code 726.73, 788.0 added to covered codes
7/2003: Reviewed by MPAC; ESWT for pancreatic stones remains investigational, FEP exception added, Sources updated
11/2003: Reviewed by MPAC, Dornier Epos™ Ultra extracorporeal shock wave lithotripsy (ESWL) device added to “Description” , policy “Title’ changed from Extracorporeal Shock Wave Lithotripsy (ESWL) to Extracorporeal Shock Wave Treatment (ESWT), ESWL changed to ESWT as appropriate, hyperlink inserted, FEP exception musculoskeletal conditions added
1/21/2004: Code Reference section reviewed; no changes
1/23/2004: Code Reference section updated, ICD-9 diagnosis code range 727.00-727.09 listed separately, non-covered ICD-9 diagnosis codes 527.5, 574.20-574.21, 577.8, 719.47, 719.87, 726.10-726.12, 726.31, 726.32, 726.5, 726.61, 726.64, 726.8, 727.42, 727.60-726.69, 727.81, 727.89, 733.81, 733.82, 733.93, 733.94, 733.95 deleted, all non-covered codes were added 5-7-2002 except 574.00-574.91 code range added 4-8-2003 which was deleted also
6/4/2004: Code Reference section updated, ICD-9 diagnosis code 592.1, 592.9, 726.71, 726.72, 726.73, 726.79, 726.90, 727.00, 727.01, 727.02, 727.03, 727.04, 727.05, 727.06, 727.09, 727.82, 728.71, 728.79, 728.86, 728.89, 729.4, 788.0 deleted from covered codes
7/9/2004: FEP exception for kidney stones added
11/18/2004: Reviewed by MPAC, ESWT for pancreatic stones remains investigational
2/18/2005: Policy reviewed, Sources updated
7/19/2005: Code Reference section updated, CPT code 00872, 00873 added covered codes, ICD-9 procedure code 98.51, 98.59 description revised covered codes, CPT code 48999 added non-covered codes
3/24/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
3/28/2006: Policy reviewed, no changes
10/16/2006: Peyronie's Disease added to the policy section as investigational
3/28/2007: Policy reviewed, no changes
6/15/2007: Policy reviewed, description updated to include musculoskeletal conditions plantar fasciitis and lateral epicondylitis. ESWT for plantar fasciitis changed to investigational. Removed the following policy statement: "Extracorporeal Shock Wave Treatment (ESWT) for chronic plantar fasciitis is considered medically necessary as an alternative to surgical therapy. |
A9505 | TL201 THALLOUS CL DX MCI Injectable Drugs Not on Fee Schedule | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A4642 | RRX INDIUM 111 SATUMOMAB DX 0 6MCI | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
S8080 | SCINTIMAMMO UNI W/SPL RADIOPHARM | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A4641 | RADIOPHARM DX NOC Injectable Drugs Not on Fee Schedule | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. |
A9505 | TL201 THALLOUS CL DX MCI Injectable Drugs Not on Fee Schedule | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A4642 | RRX INDIUM 111 SATUMOMAB DX 0 6MCI | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9549 | Tc99m arcitumomab | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9565 | In111 pentetreotide | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
S8080 | SCINTIMAMMO UNI W/SPL RADIOPHARM | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A4641 | RADIOPHARM DX NOC Injectable Drugs Not on Fee Schedule | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
A9500 | TECHNETIUM TC 99M SESTAMIBI IV KIT | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/29/2001: HCPCS A4642 added
2/11/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
9/10/2004: Code Reference section updated, HCPCS A4642 note "(Included in code S8080, do not report separately)" added, HCPCS A9500, A9505, Q3088, S8080 added with note "Included in code S8080, do not report separately"
8/24/2005: Code Reference section updated, HCPCS A4641 added
3/14/2006: Coding updated. HCPCS revisions added to policy
3/21/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
7/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
7/22/2008: Policy reviewed, no changes
8/26/2009: Description updated. Policy statement updated. HCPCS codes A9549 and A9565 were deleted from the coding reference section due to deleted code status. |
00100 | ANESTH SALIVARY GLAND | CPT | The more than 7,000 five-character CPT Codes are an important part of the billing process. They are used by insurers to aid in determining the amount of reimbursement the physician or healthcare provider will receive for services rendered. - CPT Codes are copyrighted and maintained by the American Medical Association (AMA). Updated annually, these codes fall into three major categories. - Category I- The code range is 00100 to 99499. |
00100 | ANESTH SALIVARY GLAND | CPT | - CPT Codes are copyrighted and maintained by the American Medical Association (AMA). Updated annually, these codes fall into three major categories. - Category I- The code range is 00100 to 99499. Each five-digit code has a corresponding description of the procedure or service. - Category II – These are more of alphanumeric tracking codes to describe clinical components in-clinic services or evaluation and management. |
1999 | ANESTHESIOLOGY GROUP | CPT | CPT codes help government agencies keep tabs on the value and prevalence of particular procedures whereas hospitals may evaluate the efficiency of divisions and individuals in their facility using Current Procedural Terminology Codes. CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. |
00100 | ANESTH SALIVARY GLAND | CPT | CPT codes help government agencies keep tabs on the value and prevalence of particular procedures whereas hospitals may evaluate the efficiency of divisions and individuals in their facility using Current Procedural Terminology Codes. CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. |
01999 | Unlisted anesth procedure | CPT | CPT codes help government agencies keep tabs on the value and prevalence of particular procedures whereas hospitals may evaluate the efficiency of divisions and individuals in their facility using Current Procedural Terminology Codes. CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. |
1999 | ANESTHESIOLOGY GROUP | CPT | CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. |
00100 | ANESTH SALIVARY GLAND | CPT | CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. |
10000 | Incision & drainage of sebaceous cyst-one | CPT | CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. |
01999 | Unlisted anesth procedure | CPT | CPT Code Categories
Category I is concerning procedures and contemporary medical practices performed across the United States. This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. |
1999 | ANESTHESIOLOGY GROUP | CPT | This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. Radiology (70000-79999) –including ultrasound, mammography, bone/joint, oncology, and nuclear medicine. |
00100 | ANESTH SALIVARY GLAND | CPT | This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. Radiology (70000-79999) –including ultrasound, mammography, bone/joint, oncology, and nuclear medicine. |
10000 | Incision & drainage of sebaceous cyst-one | CPT | This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. Radiology (70000-79999) –including ultrasound, mammography, bone/joint, oncology, and nuclear medicine. |
01999 | Unlisted anesth procedure | CPT | This category is generally identified with the 5-character CPT Codes that identify a service or procedure sanctioned by the FDA and performed by a physician or healthcare professional. This category is broken down into six sections and they are:
Evaluation and Management (99201-99499) – which includes hospital observation services, office, and other outpatient services, consultations, hospital inpatient services, emergency department, critical care services, nursing facility services, custodial care services and so on. Anesthesiology (00100–01999; 99100–99150) – which includes procedures of the head, neck, thorax, intrathoracic, spine and spinal column, upper and lower abdomen, obstetrics and more. Surgery (10000–69990) – which includes general surgery, integumentary system, musculoskeletal system, respiratory system, cardiovascular system, digestive system, urinary system, eye and reproductive, to name a few. Radiology (70000-79999) –including ultrasound, mammography, bone/joint, oncology, and nuclear medicine. |
99199 | Unlisted special svc px/rprt | CPT | Radiology (70000-79999) –including ultrasound, mammography, bone/joint, oncology, and nuclear medicine. Pathology and Laboratory (80000–89398) – including organ or disease-oriented panels, drug testing, therapeutic drug assays, evocative/suppression testing, consultations (clinical pathology), urinalysis, transfusion medicine, microbiology and more. Medicine (90281–99099; 99151–99199; 99500–99607) – including vaccines, toxoids, psychiatry, biofeedback, dialysis, gastroenterology, ophthalmology, special otorhinolaryngologic services, cardiovascular, noninvasive vascular diagnostic studies, pulmonary, allergy and clinical immunology, endocrinology and more. Category II pertains to clinical laboratory services. CPT codes for this category consist of secondary tracking codes employed for collecting information regarding the quality of care rendered, and performance measurement. |
99199 | Unlisted special svc px/rprt | CPT | Medicine (90281–99099; 99151–99199; 99500–99607) – including vaccines, toxoids, psychiatry, biofeedback, dialysis, gastroenterology, ophthalmology, special otorhinolaryngologic services, cardiovascular, noninvasive vascular diagnostic studies, pulmonary, allergy and clinical immunology, endocrinology and more. Category II pertains to clinical laboratory services. CPT codes for this category consist of secondary tracking codes employed for collecting information regarding the quality of care rendered, and performance measurement. The use of these codes is not mandatory. Breakdown of Category II CPT Codes are:
- Composite Measures (0001F-0015F)
- Patient Management (0500F-0575F)
- Patient History (1000F-1220F)
- Physical Examination (2000F-2050F)
- Diagnostic/Screening Processes or Results (3006F-3573F)
- Therapeutic, Preventive or Other Interventions (4000F-4306F)
- Follow-up or Other Outcomes (5005F-5100F)
- Patient Safety (6005F-6045F)
- Structural Measures (7010F-7025F)
Category III is reserved for emerging technologies, with CPT codes of 0016T-0207T. |
11710 | Debridement of nails-electric grinder-five or less | CPT | For example, a doctor may provide documentation of a mole removed from the torso of a patient via cryoablation (essentially, freezing the mole). The medical biller and coder would look at the procedure documentation and decide which codes correspond to the diagnosis and procedure listed. In the case of this example, a coder would select the CPT code 11710 (destruction of benign lesions or skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure, and the ICD-9-CM code 216.5 (benign neoplasm of skin of trunk, except scrotum) for the diagnosis. The bulk of the medical coding portion of the billing process involves turning procedure reports into correct medical code, then entering it into the system for the claims process. Medical coders spend their day taking procedure documentation, looking up the proper codes, and entering that information into their claims software. |
28309 | PR OSTEOT W/WO LNGTH SHRT/ANGULAR CORRJ METAR MLT | HCPCS | A cast is placed on the foot during the tenotomy procedure, but this is not billable because it’s not a separately identifiable procedure. More extensive procedures may be necessary if the deformity is severe. Some examples of these are hammertoe correction (28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)) and osteotomies (code range 28300-28309, depending on the affected bones in the foot). DME Supply Coding
For the bracing, the following HCPCS Level II supply codes may be used, as prescribed by the physician:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
L2280 Addition to lower extremity, molded inner boot
L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
L2768 Orthotic side bar disconnect device, per bar
Billing these codes depends on your facility’s DME status, and if you are billing for the orthotic providers that create the boots and ankle-foot orthosis (AFOs), also known as foot-drop braces. As the child grows, new AFOs and bigger bars will be required and may be billed, accordingly. |
L1960 | HC SUPPLY ANKLE FOOT ORTHOSIS POSTERIOR SOLID ANKLE CUSTOM - L1960 | HCPCS | A cast is placed on the foot during the tenotomy procedure, but this is not billable because it’s not a separately identifiable procedure. More extensive procedures may be necessary if the deformity is severe. Some examples of these are hammertoe correction (28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)) and osteotomies (code range 28300-28309, depending on the affected bones in the foot). DME Supply Coding
For the bracing, the following HCPCS Level II supply codes may be used, as prescribed by the physician:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
L2280 Addition to lower extremity, molded inner boot
L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
L2768 Orthotic side bar disconnect device, per bar
Billing these codes depends on your facility’s DME status, and if you are billing for the orthotic providers that create the boots and ankle-foot orthosis (AFOs), also known as foot-drop braces. As the child grows, new AFOs and bigger bars will be required and may be billed, accordingly. |
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