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17000
PR DESTRUCTION PREMALIGNANT LESION 1ST
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11313
Shave skin lesion >2.0 cm
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11201
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA_ EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11400
Removal of noncancer skin growth of body, arms, or legs, 0.5 cm or less
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
17004
PR DESTRUCTION PREMALIGNANT LESION 15/>
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
56515
PR DESTRUCTION LESIONS VULVA EXTENSIVE
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11200
Shave-Benign, Skin Tags1-15-FAC
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
17110
PR DESTRUCTION BENIGN LESIONS UP TO 14
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
56501
PR DESTRUCTION LESIONS VULVA SIMPLE
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
54065
PR DSTRJ LESION PENIS EXTENSIVE
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
57061
PR DESTRUCTION VAGINAL LESIONS SIMPLE
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11446
Removal of noncancer skin growth of face, ears, eyelids, nose, lips, or mouth, more than 4.0 cm
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
54050
PR DSTRJ LESION PENIS SIMPLE CHEMICAL
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
17111
PR DESTRUCTION BENIGN LESIONS 15/>
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
11300
Shaving of skin growth of body, arms, or legs, 0.5 cm or less
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
57065
PR DESTRUCTION VAGINAL LESIONS EXTENSIVE
HCPCS
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development o...
17000
PR DESTRUCTION PREMALIGNANT LESION 1ST
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11313
Shave skin lesion >2.0 cm
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11201
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA_ EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11400
Removal of noncancer skin growth of body, arms, or legs, 0.5 cm or less
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
17004
PR DESTRUCTION PREMALIGNANT LESION 15/>
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
56515
PR DESTRUCTION LESIONS VULVA EXTENSIVE
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11200
Shave-Benign, Skin Tags1-15-FAC
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
17110
PR DESTRUCTION BENIGN LESIONS UP TO 14
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
56501
PR DESTRUCTION LESIONS VULVA SIMPLE
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
54065
PR DSTRJ LESION PENIS EXTENSIVE
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
57061
PR DESTRUCTION VAGINAL LESIONS SIMPLE
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11446
Removal of noncancer skin growth of face, ears, eyelids, nose, lips, or mouth, more than 4.0 cm
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
54050
PR DSTRJ LESION PENIS SIMPLE CHEMICAL
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
17111
PR DESTRUCTION BENIGN LESIONS 15/>
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
11300
Shaving of skin growth of body, arms, or legs, 0.5 cm or less
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
57065
PR DESTRUCTION VAGINAL LESIONS EXTENSIVE
HCPCS
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th cha...
0064T
Spectroscop Eval Expired Gas
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 mus...
83987
Exhaled breath condensate
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 mus...
94799
Other service or procedure on lung
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 mus...
0140T
Exhaled breath condensate ph
CPT
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
84999
UNLISTED CHEMISTRY PROCEDURE
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 mus...
0064T
Spectroscop Eval Expired Gas
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: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T add...
83987
Exhaled breath condensate
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: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T add...
94799
Other service or procedure on lung
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: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T add...
0140T
Exhaled breath condensate ph
CPT
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T add...
84999
UNLISTED CHEMISTRY PROCEDURE
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: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T add...
0064T
Spectroscop Eval Expired Gas
HCPCS
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added 12/22/2005: Collection and...
83987
Exhaled breath condensate
HCPCS
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added 12/22/2005: Collection and...
94799
Other service or procedure on lung
HCPCS
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added 12/22/2005: Collection and...
0140T
Exhaled breath condensate ph
CPT
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added 12/22/2005: Collection and...
84999
UNLISTED CHEMISTRY PROCEDURE
HCPCS
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) 4/29/2004: Code Reference section completed 3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added 12/22/2005: Collection and...
0140T
Exhaled breath condensate ph
CPT
02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: ...
0140T
Exhaled breath condensate ph
CPT
02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: ...
0140T
Exhaled breath condensate ph
CPT
Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: Policy reviewed; no changes. 07/20/2015: Policy title changed from "Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements in the...
0140T
Exhaled breath condensate ph
CPT
Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: Policy reviewed; no changes. 07/20/2015: Policy title changed from "Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements in the Diagnosis and Management of Asthma and Other Respirat...
15878
Suction lipectomy upr extrem
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
97033
SBT PTA IONTOPHORESIS EACH 15 MIN
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
17999
UNLISTED PROC SKIN SUBQ
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary pe...
J0587
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
HCPCS
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary pe...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per regio...
J0587
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
HCPCS
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per regio...
E0218
Fluid circ cold pad w pump
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 mus...
E0236
Pump for water circulating pad
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 mus...
E0218
Fluid circ cold pad w pump
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 HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added 5/2/2002: Type of Service and Place of Service deleted ...
E0236
Pump for water circulating pad
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 HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added 5/2/2002: Type of Service and Place of Service deleted ...
93740
Temperature gradient studies
HCPCS
There is an absence of evidence of the impact of DIRI on health outcomes. The BioScanIR System (OmniCorder Technologies, Inc., Bohemia, NY) is an example of a DIRI device that is commercially available. |CPT Codes / HCPCS Codes / ICD-9 Codes| |CPT codes not covered for indications listed in the CPB:| |93740||Temperatur...
93740
Temperature gradient studies
HCPCS
The BioScanIR System (OmniCorder Technologies, Inc., Bohemia, NY) is an example of a DIRI device that is commercially available. |CPT Codes / HCPCS Codes / ICD-9 Codes| |CPT codes not covered for indications listed in the CPB:| |93740||Temperature gradient studies| |ICD-9 codes not covered for indications listed in the...
S8035
MAGNETIC SOURCE IMAGING
HCPCS
HCPCS code S8035 was previously added to codes table. FEP verbiage added to the Policy Exceptions section. Deleted outdated references from the Sources section. 04/20/2011: Policy reviewed; no changes. 11/30/2012: Policy statement revised to state that magnetoencephalography/magnetic source imaging as part of the preop...
87476
LYME DISEASE PCR
HCPCS
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a...
87477
Lyme dis dna quant
HCPCS
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a...
87475
Lyme dis dna dir probe
HCPCS
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a...
87476
LYME DISEASE PCR
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 HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disea...
87477
Lyme dis dna quant
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 HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disea...
87475
Lyme dis dna dir probe
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 HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disea...
J0550
Penicillin g benzathine inj
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
J0540
Penicillin g benzathine inj
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
87476
LYME DISEASE PCR
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
J0530
Penicillin g benzathine inj
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
87477
Lyme dis dna quant
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
87475
Lyme dis dna dir probe
HCPCS
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC) 5/1/2002: Type of Service and Place of Service deleted 3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with B...
J0550
Penicillin g benzathine inj
HCPCS
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis 7/19/2007: Reviewed and approved by MPAC 7/10/2009: Policy reviewed, no changes 12/15/2009: Coding Section revised with 2010 CPT4 and HCP...
J0540
Penicillin g benzathine inj
HCPCS
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis 7/19/2007: Reviewed and approved by MPAC 7/10/2009: Policy reviewed, no changes 12/15/2009: Coding Section revised with 2010 CPT4 and HCP...
J0530
Penicillin g benzathine inj
HCPCS
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis 7/19/2007: Reviewed and approved by MPAC 7/10/2009: Policy reviewed, no changes 12/15/2009: Coding Section revised with 2010 CPT4 and HCP...
J0550
Penicillin g benzathine inj
HCPCS
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serolo...
J0540
Penicillin g benzathine inj
HCPCS
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serolo...
J0530
Penicillin g benzathine inj
HCPCS
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serolo...
J0580
Penicillin g benzathine inj
HCPCS
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Re...
J0560
Penicillin g benzathine inj
HCPCS
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Re...
J0570
Buprenorphine implant, 74.2 mg
HCPCS
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Re...
J0580
Penicillin g benzathine inj
HCPCS
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoatt...
J0560
Penicillin g benzathine inj
HCPCS
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoatt...
J0570
Buprenorphine implant, 74.2 mg
HCPCS
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoatt...
J0561
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
HCPCS
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoatt...
J0580
Penicillin g benzathine inj
HCPCS
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary polic...
J0560
Penicillin g benzathine inj
HCPCS
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary polic...
J0570
Buprenorphine implant, 74.2 mg
HCPCS
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary polic...
J0561
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
HCPCS
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary polic...
J0580
Penicillin g benzathine inj
HCPCS
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdo...
J0560
Penicillin g benzathine inj
HCPCS
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdo...
J0570
Buprenorphine implant, 74.2 mg
HCPCS
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdo...
J0561
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
HCPCS
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdo...
0109
Med-Surg
RC
The Regional Committee for Europe adopted the JMF in September 2018. The majority of JMF indicators in the Gateway are linked to existing databases in the Gateway. EUR/RC68/10 Rev.1 Briefing note on the expert group deliberations and recommended common set of indicators for a joint monitoring framework EUR/RC68(1): Joi...