code stringlengths 4 12 | description stringlengths 2 264 | codetype stringclasses 8
values | context stringlengths 160 15.5k |
|---|---|---|---|
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
E0936 | CPM device, other than knee | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D2970 | Temp crown (fractured tooth) | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D0290 | Skull/facial bone image | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
A4595 | TENS suppl 2 lead per month | HCPCS | ICD-9 procedure codes 76.2, 76.73-76.76, 76.91, 76.92, 80.19 removed from covered table. ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/... |
D7995 | Synthetic graft facial bones | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
A4630 | Repl bat t.e.n.s. own by pt | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D2940 | PR PROTECTIVE RESTORATION | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D2915 | Recement cast or prefab post | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
E0936 | CPM device, other than knee | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D2970 | Temp crown (fractured tooth) | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D0290 | Skull/facial bone image | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
A4595 | TENS suppl 2 lead per month | HCPCS | ICD-9 diagnosis codes 170.9 and 198.5 removed from covered table. HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy d... |
D7995 | Synthetic graft facial bones | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
A4630 | Repl bat t.e.n.s. own by pt | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D2940 | PR PROTECTIVE RESTORATION | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D2915 | Recement cast or prefab post | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D5225 | PR MAXILLARY PARTIAL DENTURE FLEX BASE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D2971 | PR ADD PROC NEW CROWN XST PART DENTURE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D2934 | PR PREFB ESTHET COAT STNLSS STEEL CRWN | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
E0936 | CPM device, other than knee | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D5226 | PR MANDIBULAR PART DENTURE FLEX BASE | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D2970 | Temp crown (fractured tooth) | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
D0290 | Skull/facial bone image | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
A4595 | TENS suppl 2 lead per month | HCPCS | HCPCS D0290, D7995, and S8262 removed from covered. HCPCS A4595, A4630, D2915, D2934, D2970, D2971, D5225, D5226, D2940, E0731, E0936 added to non-covered table. 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Po... |
64570 | Remove vagus n eltrd | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Cod... |
64568 | PR OPEN IMPLANTATION CRANIAL NERVE NEA & PULSE GEN | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Cod... |
64569 | Revise/repl vagus n eltrd | HCPCS | 12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
07/08/2010: Policy description updated regarding etiology and treatment approaches. Policy statement revised to acupuncture as an investigational non-surgical treatment. 10/19/2010: Annual ICD-9 code update: added new code 784.92 to the Covered Cod... |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | Medical Necessity documentation and a treatment plan, including charges for each service, must be submitted to and approved prior to the commencement of treatment. No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider. Added CPT codes D0368, D0384,... |
S8262 | MANDIB ORTHO REPOSITION DEVICE EACH | CPT | No benefits will be provided for temporomandibular joint disorder when a Member receives services from a Non-Network Provider. Added CPT codes D0368, D0384, and S8262 to the Covered Codes table. Removed deleted CPT code D0360 from the Code Reference section. 09/19/2014: Policy reviewed; description updated. Policy stat... |
E0485 | Oral device/appliance prefab | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes t... |
E0486 | Oral device/appliance cusfab | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes t... |
20606 | PROFEE ARTHROCENTESIS OR INJ JNT OR BURS | HCPCS | Added the following new 2015 CPT code(s) to the Code Reference section: 20606. 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes t... |
E0485 | Oral device/appliance prefab | HCPCS | 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E048... |
E0486 | Oral device/appliance cusfab | HCPCS | 09/01/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E048... |
E0485 | Oral device/appliance prefab | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
E0486 | Oral device/appliance cusfab | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
D5875 | Prosthesis modification | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
D5630 | Rep partial denture clasp | HCPCS | Extended ICD-9 diagnosis code 524.8 to the fifth digit as 524.81, 524.82, and 524.89. Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Pol... |
E0485 | Oral device/appliance prefab | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
E0486 | Oral device/appliance cusfab | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
D5875 | Prosthesis modification | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
D5630 | Rep partial denture clasp | HCPCS | Removed the following ICD-9 procedure codes from the Not Medically Necessary/Investigational Codes table: 87.17, 93.04, 93.05, 93.34, and 93.35. 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code ... |
E0485 | Oral device/appliance prefab | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
E0486 | Oral device/appliance cusfab | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
D5875 | Prosthesis modification | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
D5630 | Rep partial denture clasp | HCPCS | 09/14/2015: Added HCPCS codes E0485 and E0486 to the Covered Codes table. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy descriptio... |
D5660 | PR ADD CLASP XST PRT DENTURE-PER TOOTH | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cro... |
0340 | Nuclear Medicine - General Classification | RC | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cro... |
D5875 | Prosthesis modification | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cro... |
D0340 | PR 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cro... |
D5630 | Rep partial denture clasp | HCPCS | 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the descriptions for the following HCPCS codes: D0340, D5630, D5660, and D5875. 02/19/2016: Policy description updated regarding devices. Policy statement unchanged. SOURCE(S)Blue Cro... |
0230 | Incremental Nursing Charge - General Classification | RC | SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. Arthroscopy, temporomandib... |
0210 | Other Inpatient | RC | SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.21
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. Arthroscopy, temporomandib... |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0360 | Each additional hr 1-8 hrs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0362 | Each add sequential infusion | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0359 | Chemotherapy IV one hr initi | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated a... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
86826 | Hla x-match noncytotoxc addl | 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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
86825 | X-MATCHAHG | 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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewe... |
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