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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: 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...
G0358
IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
86826
Hla x-match noncytotoxc addl
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
86825
X-MATCHAHG
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0360
Each additional hr 1-8 hrs
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
J9000
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0364
HC BONE MARROW ASPIRATE & BIOPSY
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0362
Each add sequential infusion
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
J9999
Not otherwise classified, antineoplastic drugs
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0359
Chemotherapy IV one hr initi
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
38230
PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0361
Prolong chemo infuse>8hrs pu
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0356
HORMONAL ANTINEOPLASTIC
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
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: Reviewed by MPAC; no changes 10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359,...
G0267
Bone marrow or psc harvest
CPT
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
38241
Transplt autol hct/donor
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
38240
Transplt allo hct/donor
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
G0265
Cryopresevation Freeze+stora
CPT
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
38242
Transplt allo lymphocytes
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
G0266
Thawing + expansion froz cel
CPT
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
96445
Chemotherapy, intracavitary
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; remove...
G0267
Bone marrow or psc harvest
CPT
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
38241
Transplt autol hct/donor
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
38240
Transplt allo hct/donor
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
G0265
Cryopresevation Freeze+stora
CPT
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
38242
Transplt allo lymphocytes
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
G0266
Thawing + expansion froz cel
CPT
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
96445
Chemotherapy, intracavitary
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266...
G0267
Bone marrow or psc harvest
CPT
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
38241
Transplt autol hct/donor
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
38240
Transplt allo hct/donor
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
G0265
Cryopresevation Freeze+stora
CPT
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
38242
Transplt allo lymphocytes
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
G0266
Thawing + expansion froz cel
CPT
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
96445
Chemotherapy, intracavitary
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96...
G0267
Bone marrow or psc harvest
CPT
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
38241
Transplt autol hct/donor
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
38240
Transplt allo hct/donor
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
G0265
Cryopresevation Freeze+stora
CPT
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
38242
Transplt allo lymphocytes
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
G0266
Thawing + expansion froz cel
CPT
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
96445
Chemotherapy, intracavitary
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
96446
PR CHEMOTX ADMN PERTL CAVITY IMPLANTED PORT/CATH
HCPCS
08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE RE...
15878
Suction lipectomy upr extrem
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...
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...
92508
Speech/hearing therapy
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92551
Test for screening hearing
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92588
PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92524
ST SPEECH BEHAVIORAL QUALI OF
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92522
ST SPEECH EVAL OF SOUND PRODUC
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92620
PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92621
PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92523
ST SPEECH EVAL SOUND W LANGUAG COMPREHEN
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
S9128
Speech therapy, in the home,
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92507
Treatment of speech, language, voice, communication, and/or hearing processing disorder
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92521
ST SPEECH EVAL OF FLUENCY
HCPCS
The use of potentially weaker OAE methods and the remarkable heterogeneity across studies does not allow for a definite conclusion whether or not the MOC reflex is altered in children with APD. The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; k...
92508
Speech/hearing therapy
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92551
Test for screening hearing
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92588
PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92524
ST SPEECH BEHAVIORAL QUALI OF
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92522
ST SPEECH EVAL OF SOUND PRODUC
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92620
PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92621
PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92523
ST SPEECH EVAL SOUND W LANGUAG COMPREHEN
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
S9128
Speech therapy, in the home,
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92507
Treatment of speech, language, voice, communication, and/or hearing processing disorder
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92521
ST SPEECH EVAL OF FLUENCY
HCPCS
The authors concluded that further carefully designed studies are needed to confirm the involvement of MOC efferents in APD; knowledge of efferent functioning in children with APD would be mechanistically and clinically beneficial. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been a...
92065
PR ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP
HCPCS
Nevertheless, the results showed that vergence treatment might help dyslexics. They stated that larger studies are needed to provide guidance in this area. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represe...
92065
PR ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP
HCPCS
They stated that larger studies are needed to provide guidance in this area. |CPT Codes / HCPCS Codes / ICD-10 Codes| |Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":| |ICD-10 codes will become effective as of October 1, 2015 :| |CPT...
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. 3/25/2004: 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...
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. 3/25/2004: 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...
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. 3/25/2004: 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...