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15.5k
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
38242
Transplt allo lymphocytes
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86812
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86822
Lymphocyte culture primed
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
38204
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.25 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPC...
96445
Chemotherapy, intracavitary
HCPCS
Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPC...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
Policy statement revised to change "stem-cell support" to "hematopoietic stem-cell transplantation" and state that autologous or allogeneic hematopoietic stem-cell transplantation is considered investigational. Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPC...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated i...
96445
Chemotherapy, intracavitary
HCPCS
Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated i...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
Policy intent unchanged. 08/21/2015: Code Reference section updated to add ICD-10 codes, removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 03/09/2016: Policy description updated regarding FDA regulations. Policy statement unchanged. Investigative definition updated i...
81003
URINE SPECIFIC GRAVITY
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...
81005
URINALYSIS
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...
81001
URINALYSIS AUTO W/SCOPE
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...
81099
URINE COLLECTION
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...
1999
ANESTHESIOLOGY GROUP
CPT
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
81015
URINE MICROSCOPIC (ONLY)
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...
81000
HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI
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...
81002
URN DIPST/TAB RGNT NONAUTO W/O
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...
81020
Urinalysis glass test
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...
81007
Urine screen for bacteria
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...
86316
IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH
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...
81003
URINE SPECIFIC GRAVITY
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81005
URINALYSIS
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81001
URINALYSIS AUTO W/SCOPE
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81099
URINE COLLECTION
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81015
URINE MICROSCOPIC (ONLY)
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81000
HC URINALYSIS, BY DIP STICK OR TABLET REAGENT; NON-AUTOMATED, WI
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
88368
PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
88367
PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
88271
MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH)
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
88299
Unlisted cytogenetic 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81002
URN DIPST/TAB RGNT NONAUTO W/O
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81020
Urinalysis glass test
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
81007
Urine screen for bacteria
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
86316
IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), 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. 8/1999: Approved by Medical Policy Advisory Committee (MPAC) 6/28/2001: Coding Reference section updated, tables added, CPT codes 81000, 81001, 81002, 81003, 81005, 81007, 81015, 8102...
88368
PR M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL
HCPCS
HCPCS 2006 revisions added to policy 12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7 4/29/2008: Policy reviewed, no changes 9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied 7/24/2009: Policy Description section updated for clarifi...
88367
PR M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN
HCPCS
HCPCS 2006 revisions added to policy 12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7 4/29/2008: Policy reviewed, no changes 9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied 7/24/2009: Policy Description section updated for clarifi...
88299
Unlisted cytogenetic study
HCPCS
HCPCS 2006 revisions added to policy 12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7 4/29/2008: Policy reviewed, no changes 9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied 7/24/2009: Policy Description section updated for clarifi...
88271
MOLECULAR CYTOGENETICS_ DNA PROBE, EACH (EG, FISH)
HCPCS
HCPCS 2006 revisions added to policy 12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7 4/29/2008: Policy reviewed, no changes 9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied 7/24/2009: Policy Description section updated for clarifi...
86316
IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH
HCPCS
HCPCS 2006 revisions added to policy 12/04/2006: Description and policy section updated. Code Reference section updated. Added CPT code 83365, and ICD-9 code 599.7 4/29/2008: Policy reviewed, no changes 9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied 7/24/2009: Policy Description section updated for clarifi...
J9000
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
HCPCS
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
G0364
HC BONE MARROW ASPIRATE & BIOPSY
HCPCS
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
38230
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
HCPCS
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology mus...
J9000
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
G0364
HC BONE MARROW ASPIRATE & BIOPSY
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
38230
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
J9000
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC) 7/19/2004: Code Reference section completed 11/18/2004: Review...
G0364
HC BONE MARROW ASPIRATE & BIOPSY
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC) 7/19/2004: Code Reference section completed 11/18/2004: Review...
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC) 7/19/2004: Code Reference section completed 11/18/2004: Review...
38230
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC) 7/19/2004: Code Reference section completed 11/18/2004: Review...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.24 per approval by Medical Policy Advisory Committee (MPAC) 7/19/2004: Code Reference section completed 11/18/2004: Review...
86825
X-MATCHAHG
HCPCS
CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/19/2007: Coding updated per 2008 CPT/HCPCS revisions 9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation...
86826
Hla x-match noncytotoxc addl
HCPCS
CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes 12/19/2007: Coding updated per 2008 CPT/HCPCS revisions 9/26/2008: Policy description updated, policy statements unchanged. "High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation...
86826
Hla x-match noncytotoxc addl
HCPCS
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
G0267
Bone marrow or psc harvest
CPT
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
G0265
Cryopresevation Freeze+stora
CPT
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
G0266
Thawing + expansion froz cel
CPT
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
86825
X-MATCHAHG
HCPCS
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
"High-dose chemotherpay" term removed from title 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 04/26/2010: Policy title revised to change “Stem-Cell Support” to “Stem-Cell Transplantation.” Policy description updated regarding conventional preparative conditioning and reduced-intensity cond...
86826
Hla x-match noncytotoxc addl
HCPCS
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
G0267
Bone marrow or psc harvest
CPT
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
G0265
Cryopresevation Freeze+stora
CPT
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
G0266
Thawing + expansion froz cel
CPT
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
86825
X-MATCHAHG
HCPCS
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
FEP verbiage added to the Policy Exceptions section. Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes.
86826
Hla x-match noncytotoxc addl
HCPCS
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
G0267
Bone marrow or psc harvest
CPT
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
G0265
Cryopresevation Freeze+stora
CPT
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
G0266
Thawing + expansion froz cel
CPT
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
86825
X-MATCHAHG
HCPCS
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
Added new CPT codes 86825 and 86826. Deleted HCPCS G0265, G0266, and G0267 from the code section as these codes were deleted on 12/31/2007. Added HCPCS S2140 and S2142 to the non-covered table. 10/21/2010: Policy reviewed; no changes. 10/05/2011: Policy reviewed; no changes.
38241
Transplt autol hct/donor
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
38240
Transplt allo hct/donor
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
38242
Transplt allo lymphocytes
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
96445
Chemotherapy, intracavitary
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
12/13/2012: Policy reviewed; no changes. 01/22/2014: Policy reviewed; no changes. 12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, an...
38241
Transplt autol hct/donor
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
38240
Transplt allo hct/donor
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
38242
Transplt allo lymphocytes
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
96445
Chemotherapy, intracavitary
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
12/11/2014: Policy reviewed; description updated. Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Pol...
38241
Transplt autol hct/donor
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
38240
Transplt allo hct/donor
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
38242
Transplt allo lymphocytes
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
96445
Chemotherapy, intracavitary
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
Policy statements unchanged. 08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations....
38241
Transplt autol hct/donor
HCPCS
08/27/2015: Code Reference section updated to add ICD-10 codes, updated the code descriptions for 38240, 38241, and 38242; removed deleted HCPCS code G0363, and removed deleted code CPT 96445 and replaced with CPT code 96446. 04/04/2016: Policy description updated regarding FDA regulations. Policy statement updated to ...