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97033
SBT PTA IONTOPHORESIS EACH 15 MIN
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
17999
UNLISTED PROC SKIN SUBQ
HCPCS
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for covera...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary pe...
J0587
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
HCPCS
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary pe...
J0585
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
HCPCS
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per regio...
J0587
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
HCPCS
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per regio...
1999
ANESTHESIOLOGY GROUP
CPT
What are CPT codes Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health prof...
00100
ANESTH SALIVARY GLAND
CPT
What are CPT codes Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health prof...
99199
Unlisted special svc px/rprt
CPT
What are CPT codes Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health prof...
01999
Unlisted anesth procedure
CPT
What are CPT codes Developed by the AMA, the Current Procedural Terminology (CPT) codes are vital in billing medical services, as well as the procedures for their reimbursement. Providers of medical services (physicians, hospitals, laboratories, outpatient facilities, non-physician practitioners, and allied health prof...
1999
ANESTHESIOLOGY GROUP
CPT
Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that in...
00100
ANESTH SALIVARY GLAND
CPT
Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that in...
99199
Unlisted special svc px/rprt
CPT
Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that in...
01999
Unlisted anesth procedure
CPT
Through its CPT Editorial Panel, the American Medical Association (AMA) maintains and annually updates the list of CPT codes. These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that in...
1999
ANESTHESIOLOGY GROUP
CPT
These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tr...
00100
ANESTH SALIVARY GLAND
CPT
These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tr...
99199
Unlisted special svc px/rprt
CPT
These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tr...
01999
Unlisted anesth procedure
CPT
These codes include five characters which are typically numeric, but some of them include a fifth alpha character. There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tr...
1999
ANESTHESIOLOGY GROUP
CPT
There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value - Category III: Tempor...
00100
ANESTH SALIVARY GLAND
CPT
There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value - Category III: Tempor...
99199
Unlisted special svc px/rprt
CPT
There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value - Category III: Tempor...
01999
Unlisted anesth procedure
CPT
There are three categories of CPT codes: - Category I: Five-digit codes that include descriptions of a procedure or service (most CPT codes are in this category) - Category II: Supplemental alphanumeric tracking codes referring to performance evaluation or clinical services with no relative value - Category III: Tempor...
G0358
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
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...
86816
HC HLA TYPING DR/DQ SINGLE AG
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...
G0360
Each additional hr 1-8 hrs
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...
38204
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
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...
86821
Lymphocyte culture mixed
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...
G0361
Prolong chemo infuse>8hrs pu
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...
86812
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
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...
86822
Lymphocyte culture primed
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...
G0359
Chemotherapy IV one hr initi
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...
86817
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
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...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
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
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...
G0362
Each add sequential infusion
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...
86813
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
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...
G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
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...
G0356
HORMONAL 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...
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...
G0358
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
86816
HC HLA TYPING DR/DQ SINGLE AG
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...
G0360
Each additional hr 1-8 hrs
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...
38204
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
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...
86821
Lymphocyte culture mixed
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...
G0361
Prolong chemo infuse>8hrs pu
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
86812
Immunologic analysis for autoimmune disease, A, B, or C, single antigen
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...
86822
Lymphocyte culture primed
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...
G0359
Chemotherapy IV one hr initi
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
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...
86817
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
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...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
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
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...
G0362
Each add sequential infusion
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...
86813
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
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...
G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
G0356
HORMONAL ANTINEOPLASTIC
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA...
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...
G0358
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86816
HC HLA TYPING DR/DQ SINGLE AG
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0360
Each additional hr 1-8 hrs
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86821
Lymphocyte culture mixed
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0361
Prolong chemo infuse>8hrs pu
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 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 # 8.01.35 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0359
Chemotherapy IV one hr initi
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86817
HC HLA TYPING; DR/DQ, MULTIPLE ANTIGENS
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 # 8.01.35 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 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0362
Each add sequential infusion
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
86813
HC HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS
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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0356
HORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.35 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 # 8.01.35 per approval by Medical Policy Advisory Committee (MPAC) 6/25/2004: Code Reference section completed 11/18/2004: Review...
G0267
Bone marrow or psc harvest
CPT
9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted...
G0266
Thawing + expansion froz cel
CPT
9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted...
G0265
Cryopresevation Freeze+stora
CPT
9/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 1/06/2009: Policy reviewed. No changes. 10/6/2009: Code reference section updated. New ICD-9 diagnosis code 209.74 added to covered table. HCPC codes G0265, G0266 and G0267 deleted from covered table due to codes were deleted...
86826
Hla x-match noncytotoxc addl
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
38215
PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
86825
X-MATCHAHG
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
38207
PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
Added Hematopoietic Stem-Cell Transplantation, Conventional Preparative Conditioning for Hematopietic Stem-Cell Transplantation, Reduced-Intensity Conditioning for Allogeneic SCT, SCT in Solid Tumors, and staging and therapy language for Germ-Cell Tumors. Policy Exceptions section was revised to include language about ...
E1340
Repair for DME - per 15 min
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...
A4556
PT ELECTRODES
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...
E0608
APNEA MONITOR
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...
A4557
Lead wires, pair
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...
E0619
Apnea monitor w recorder
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...
E0618
Apnea monitor, without recording feature
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...