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90379
Rsv Ig, Iv
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
90378
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
90772
Ther/Proph/Diag Inj, Sc/Im
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
90766
Ther/Proph/Dg Iv Inf, Add-On
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
J1565
RSV-ivig
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
90765
Ther/Proph/Diag Iv Inf, Init
HCPCS
Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis ...
90379
Rsv Ig, Iv
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
90378
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
90772
Ther/Proph/Diag Inj, Sc/Im
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
90766
Ther/Proph/Dg Iv Inf, Add-On
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
J1565
RSV-ivig
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
90765
Ther/Proph/Diag Iv Inf, Init
HCPCS
Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added 11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added. 11/2005: Approved by Pharmacy & Therapeutics (P & T...
90379
Rsv Ig, Iv
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
90378
HC RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
90772
Ther/Proph/Diag Inj, Sc/Im
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
90766
Ther/Proph/Dg Iv Inf, Add-On
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
J1565
RSV-ivig
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
90765
Ther/Proph/Diag Iv Inf, Init
HCPCS
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee 2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, ...
90379
Rsv Ig, Iv
HCPCS
Maximum of 5 doses/season added to infant age specifications. Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the C...
J1565
RSV-ivig
HCPCS
Maximum of 5 doses/season added to infant age specifications. Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the C...
90379
Rsv Ig, Iv
HCPCS
Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section upda...
J1565
RSV-ivig
HCPCS
Infant age specifications revised. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section upda...
90379
Rsv Ig, Iv
HCPCS
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy ...
J1565
RSV-ivig
HCPCS
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions. 08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy ...
0379
Anesthesia - Other Anesthesia
RC
Deleted procedure codes J1565 and 90379 from the Code Reference section. 08/28/2015: Code Reference section updated for ICD-10. 05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions. SOURCE(S)A search of the literature was completed through the MEDLINE datab...
L8604
SYRINGE DEFLUX INJ PREFILL 1ML GLASS
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
Q3031
Collagen skin test
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
78740
Ureteral reflux study
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
52327
PR CYSTO W/SUBURTRIC NJX IMPLT MATRL
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
74455
X-ray urethra/bladder
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
74450
X-ray urethra/bladder
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
L8606
SYRINGE DURASPHERE EXP 1ML
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
74420
Urography rtrgr +-kub
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
L8603
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
HCPCS
Post-operative UTI occurs more frequently in patients with persisting reflux, pre-operative BTI history and girls. The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below h...
L8604
SYRINGE DEFLUX INJ PREFILL 1ML GLASS
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
Q3031
Collagen skin test
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
78740
Ureteral reflux study
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
52327
PR CYSTO W/SUBURTRIC NJX IMPLT MATRL
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
74455
X-ray urethra/bladder
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
74450
X-ray urethra/bladder
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
L8606
SYRINGE DURASPHERE EXP 1ML
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
74420
Urography rtrgr +-kub
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
L8603
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
HCPCS
The choice of one of the dextranomer-based substances did not affect the surgical outcome and post-operative UTI development. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes wi...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
CMS is considering phasing out HCPCS. There are 3 levels within HCPCS: HCPCS Level 1 Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2 Level 2 consists of non-physician services such as ambulatory care and durable ...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
There are 3 levels within HCPCS: HCPCS Level 1 Consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric (as opposed to alphabetic like the index). HCPCS Level 2 Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCP...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
HCPCS Level 2 Level 2 consists of non-physician services such as ambulatory care and durable medical goods such as prosthetics. HCPCS Level 3 Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on Decemb...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
HCPCS Level 3 Level 3 consisted of state-level medical coding codesets. The HIPAA Act of 1996 required a nationwide standard for medical coding. As a result, level 3 was discontinued on December 31, 2003. Current Procedural Terminology (CPT) is an outpatient medical coding codeset that is copy-written by the American M...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
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...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
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...
61548
Removal of pituitary gland
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...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
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...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
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...
G0340
Robt lin-radsurg fractx 2-5
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...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
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...
G0339
Robot lin-radsurg com, first
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...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
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...
S8030
Tantalum ring application
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...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
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...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
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...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
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...
61795
Brain surgery using computer
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...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
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...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
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...
61548
Removal of pituitary gland
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...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
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...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
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...
G0340
Robt lin-radsurg fractx 2-5
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...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
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...
G0339
Robot lin-radsurg com, first
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...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
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...
S8030
Tantalum ring application
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...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
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...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
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...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
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...
61795
Brain surgery using computer
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...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
61548
Removal of pituitary gland
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
G0339
Robot lin-radsurg com, first
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
S8030
Tantalum ring application
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
61795
Brain surgery using computer
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
61548
Removal of pituitary gland
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
G0339
Robot lin-radsurg com, first
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
S8030
Tantalum ring application
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...