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15.5k
77326
Brachytx isodose calc simp
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
C2639
SEED BRACHYTHERAPY IODINE-125 NEEDLE LOOSE TRAY STERILE
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77762
HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
76965
Echo guidance radiotherapy
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
Q3001
Radioelements for brachytherapy, any type, each
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77327
Brachytx isodose calc interm
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
C2640
HC Palladium-103 Stranded
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77404
Radiation treatment delivery
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77799
HC UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77778
HC ASRG INTERSTIT RADIOELEM APPLI
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77403
Radiation treatment delivery
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
55859
Percut/needle insert, pros
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77761
HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77406
Radiation treatment delivery
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77328
Brachytx isodose plan compl
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77777
Apply interstit radiat inter
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
1999
ANESTHESIOLOGY GROUP
CPT
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
76873
HC PROSTATE VOLUME STUDY
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77402
HC RAD TX> 1MEV, SIMPLE
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77763
HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
77776
Apply interstit radiat simpl
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
C2641
HC Palladium-103 Seed
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 HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section u...
C1715
SET BRACHYTHERAPY 20CM BEVEL 18GA 2 PART HUB DESIGN STABILIZATION
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77326
Brachytx isodose calc simp
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
C2639
SEED BRACHYTHERAPY IODINE-125 NEEDLE LOOSE TRAY STERILE
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77762
HC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
76965
Echo guidance radiotherapy
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
Q3001
Radioelements for brachytherapy, any type, each
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77327
Brachytx isodose calc interm
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
C2640
HC Palladium-103 Stranded
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77404
Radiation treatment delivery
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77799
HC UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77778
HC ASRG INTERSTIT RADIOELEM APPLI
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77403
Radiation treatment delivery
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
55859
Percut/needle insert, pros
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77761
HC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77406
Radiation treatment delivery
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77328
Brachytx isodose plan compl
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77777
Apply interstit radiat inter
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
1999
ANESTHESIOLOGY GROUP
CPT
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
76873
HC PROSTATE VOLUME STUDY
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77402
HC RAD TX> 1MEV, SIMPLE
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77763
HC INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
77776
Apply interstit radiat simpl
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
C2641
HC Palladium-103 Seed
HCPCS
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC) 8/1999: Addition of medically necessary indication approved by MPAC 5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added 7/13/2001: Policy exception for FEP added 2/14/2002: I...
G6003
Radiation treatment delivery
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
G6005
Radiation treatment delivery
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
77318
HC BRACHYTX ISODOSE PLAN, CPLX
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
77402
HC RAD TX> 1MEV, SIMPLE
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
77316
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
77317
HC BRACHYTX ISODOSE PLAN, INTRMED
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
G6006
Radiation treatment delivery
HCPCS
Policy statements unchanged. Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS ...
G6003
Radiation treatment delivery
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
G6005
Radiation treatment delivery
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
77318
HC BRACHYTX ISODOSE PLAN, CPLX
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
77402
HC RAD TX> 1MEV, SIMPLE
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
77316
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
77317
HC BRACHYTX ISODOSE PLAN, INTRMED
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
G6006
Radiation treatment delivery
HCPCS
Policy guidelines updated regarding active surveillance and prostate cancer risk criteria. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08...
G6003
Radiation treatment delivery
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
G6005
Radiation treatment delivery
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
77318
HC BRACHYTX ISODOSE PLAN, CPLX
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
77402
HC RAD TX> 1MEV, SIMPLE
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
77316
HC CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
77317
HC BRACHYTX ISODOSE PLAN, INTRMED
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
G6006
Radiation treatment delivery
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, 77318. CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23.
77402
HC RAD TX> 1MEV, SIMPLE
HCPCS
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
G6003
Radiation treatment delivery
HCPCS
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
G6005
Radiation treatment delivery
HCPCS
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
G6006
Radiation treatment delivery
HCPCS
CPT code description for 77402 revised; effective 01/01/2015. Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section.
C2699
Brachytx, non-stranded, NOS
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
G6003
Radiation treatment delivery
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
G6005
Radiation treatment delivery
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2637
Brachy,non-str,Ytterbium-169
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2642
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2698
Brachytx, stranded, NOS
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2636
HC Civastring P103/Mm Cms Study
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2643
HB CESIUM 131 NS SEED PER SOURCE
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
G6006
Radiation treatment delivery
HCPCS
Added the following new 2015 HCPCS codes G6003, G6005, G6006. 08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699.
C2699
Brachytx, non-stranded, NOS
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2642
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2637
Brachy,non-str,Ytterbium-169
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2698
Brachytx, stranded, NOS
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2636
HC Civastring P103/Mm Cms Study
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2643
HB CESIUM 131 NS SEED PER SOURCE
HCPCS
08/25/2015: Code Reference section updated for ICD-10. Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices.
C2699
Brachytx, non-stranded, NOS
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2642
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2637
Brachy,non-str,Ytterbium-169
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2698
Brachytx, stranded, NOS
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2636
HC Civastring P103/Mm Cms Study
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2643
HB CESIUM 131 NS SEED PER SOURCE
HCPCS
Added ICD-9 procedure code 92.23. Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiot...
C2699
Brachytx, non-stranded, NOS
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
C2642
SEED BRACHYTHERAPY GAMMA TILE THERAPY BIORESORBABLE COLLAGEN TILE IMPLANTED WITH CESIUM-131 RADIOACTIVE SEEDS
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
C2637
Brachy,non-str,Ytterbium-169
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
C2698
Brachytx, stranded, NOS
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
C2636
HC Civastring P103/Mm Cms Study
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
C2643
HB CESIUM 131 NS SEED PER SOURCE
HCPCS
Removed ICD-9 procedure codes 60.99 and 92.28 from the Code Reference section. Added HCPCS codes C2636, C2637, C2642, C2643, C2698, and C2699. 11/02/2015: Policy description updated regarding devices. Medically necessary policy statement updated to change "radiation therapy" to "radiotherapy." Policy guidelines updated...
0049T
External circulation assist
CPT
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of m...
33978
Remove ventricular device
HCPCS
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of m...
33977
Remove ventricular device
HCPCS
For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of m...