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15.5k
G0360
Each additional hr 1-8 hrs
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38204
PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38213
PR TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38215
PR TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0361
Prolong chemo infuse>8hrs pu
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38211
Tumor cell deplete of harvst
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38207
PR TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38208
Thaw preserved stem cells
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0359
Chemotherapy IV one hr initi
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38210
T-cell depletion of harvest
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38230
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38212
Rbc depletion of harvest
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
J9000
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0364
HC BONE MARROW ASPIRATE & BIOPSY
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
38205
PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0362
Each add sequential infusion
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0356
HORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "Allogeneic Stem Cell Transplant" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.22 8/19/2004: Code Reference section completed 11/18/2004: Reviewed by MPAC; no changes 10/27/2005: Code Reference section updated; CPT-4 codes 38204, 38205, 38207, 38...
G0267
Bone marrow or psc harvest
CPT
ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 proc...
G0266
Thawing + expansion froz cel
CPT
ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 proc...
G0265
Cryopresevation Freeze+stora
CPT
ICD9 2006 revisions added to policy 12/21/2006: Policy reviewed, no changes 9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 proc...
G0267
Bone marrow or psc harvest
CPT
ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 ...
G0266
Thawing + expansion froz cel
CPT
ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 ...
G0265
Cryopresevation Freeze+stora
CPT
ICD-9 2007 revisions added to policy 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 9/28/2009: Code reference section updated. New ICD-9 diagnosis code 285.3 added to covered table. ICD-9 procedure code 284.8 deleted from covered table due to code was deleted as of 9-30-2007. HCPC codes G0265, G0266 and G0267 ...
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...
A4650
Implant radiation dosimeter
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
61797
Srs cran les simple addl
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
G0251
Linear acc based stero radio
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
77372
Srs linear based
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
77432
Stereotactic radiation trmt
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
G0339
Robot lin-radsurg com, first
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
63621
Srs spinal lesion addl
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
77371
HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
77373
Sbrt delivery
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
G0173
STEREO RADOISURGERY,COMPLETE
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
63620
Srs spinal lesion
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
77435
HC STEREOTACTIC BODY RADIATION MANAGEMENT
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
A4648
WIRE LOCAL SPECBOARD
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
61798
Srs cranial lesion complex
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
61800
PR APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
61799
Srs cran les complex addl
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
20660
PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
61796
Srs cranial lesion simple
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
32701
Thorax stereo rad targetw/tx
HCPCS
For treatment to additional lesions, further clinical justification may be needed. Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All ot...
A4650
Implant radiation dosimeter
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
61797
Srs cran les simple addl
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
G0251
Linear acc based stero radio
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
77372
Srs linear based
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
77432
Stereotactic radiation trmt
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
G0339
Robot lin-radsurg com, first
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
63621
Srs spinal lesion addl
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
77371
HC RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
77373
Sbrt delivery
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
G0173
STEREO RADOISURGERY,COMPLETE
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
63620
Srs spinal lesion
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
77435
HC STEREOTACTIC BODY RADIATION MANAGEMENT
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
A4648
WIRE LOCAL SPECBOARD
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
61798
Srs cranial lesion complex
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
61800
PR APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
61799
Srs cran les complex addl
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
20660
PR APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
61796
Srs cranial lesion simple
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
32701
Thorax stereo rad targetw/tx
HCPCS
Stereotactic body radiation therapy is considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required and clinically appropriate, including: All other clinical sites or indications are considered experimental and investigational b...
A9500
TECHNETIUM TC 99M SESTAMIBI IV KIT
HCPCS
Scintimammography, breast-specific gamma imaging (BSGI), and molecular breast imaging (MBI) are considered investigational in all applications, including but not limited to their use as an adjunct to mammography or in staging the axillary lymph nodes. Preoperative or intraoperative sentinel lymph node detection using h...
A9500
TECHNETIUM TC 99M SESTAMIBI IV KIT
HCPCS
Preoperative or intraoperative sentinel lymph node detection using handheld or mounted mobile gamma cameras is considered investigational. The most commonly used radiopharmaceutical used in for BSGI or MBI is technetium Tc 99m sestamibi (marketed by Draxis Specialty Pharmaceuticals Inc., Cardinal Health 414, LLC, Malli...