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G0357
IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC) 7/13/2004: Code Reference section completed 7/1/2004: Reviewed...
G0356
HORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC) 7/13/2004: Code Reference section completed 7/1/2004: Reviewed...
G0266
Thawing + expansion froz cel
CPT
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC) 7/13/2004: Code Reference section completed 7/1/2004: Reviewed...
G0355
CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC) 7/13/2004: Code Reference section completed 7/1/2004: Reviewed...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.26 per approval by Medical Policy Advisory Committee (MPAC) 7/13/2004: Code Reference section completed 7/1/2004: Reviewed...
86826
Hla x-match noncytotoxc addl
HCPCS
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
G0267
Bone marrow or psc harvest
CPT
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
G0265
Cryopresevation Freeze+stora
CPT
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
G0266
Thawing + expansion froz cel
CPT
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
86825
X-MATCHAHG
HCPCS
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
CPT4/HCPCS revisions added to policy 5/18/2007: Policy reviewed, no changes 12/20/2007: Coding updated per 2008 CPT/HCPCS revisions 7/14/2008: Policy updated; terminology modified but materially unchanged. High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplanta...
86826
Hla x-match noncytotoxc addl
HCPCS
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
G0267
Bone marrow or psc harvest
CPT
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
G0265
Cryopresevation Freeze+stora
CPT
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
G0266
Thawing + expansion froz cel
CPT
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
86825
X-MATCHAHG
HCPCS
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
High dose chemotherapy terminology removed from title and policy statement and replaced with stem cell transplantation (SCT). High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual...
86826
Hla x-match noncytotoxc addl
HCPCS
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
G0267
Bone marrow or psc harvest
CPT
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
G0363
IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS
HCPCS
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
S2140
Cord blood harvesting for transplantation, allogeneic
HCPCS
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
G0265
Cryopresevation Freeze+stora
CPT
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
G0266
Thawing + expansion froz cel
CPT
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
86825
X-MATCHAHG
HCPCS
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
S2142
Cord blood-derived stem-cell transplantation, allogeneic
HCPCS
High dose chemotherapy will allogeneic stem cell support changed to investigational for treatment of AML relapsing after prior therapy with HDC and autologous stem cell support 9/11/2008: Annual ICD-9 updates effective 10-1-2008 applied 1/6/2009: Policy reviewed, "prior authorization before evaluation" deleted 8/07/200...
G6015
Radiation tx delivery imrt
HCPCS
Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to t...
77386
HC IMRT COMPLEX
HCPCS
Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to t...
77385
HC IMRT SIMPLE
HCPCS
Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to t...
G6016
PR DELIVERY COMP IMRT
HCPCS
Second medically necessary policy statement revised to change "is" to "may be." Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to t...
G6015
Radiation tx delivery imrt
HCPCS
Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS c...
77386
HC IMRT COMPLEX
HCPCS
Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS c...
77385
HC IMRT SIMPLE
HCPCS
Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS c...
G6016
PR DELIVERY COMP IMRT
HCPCS
Added the following statement: Intensity-modulated radiation therapy is not medically necessary for the treatment of thyroid cancers for all indications not meeting the criteria above. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS c...
G6015
Radiation tx delivery imrt
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section...
77386
HC IMRT COMPLEX
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section...
77385
HC IMRT SIMPLE
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section...
G6016
PR DELIVERY COMP IMRT
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section...
G6015
Radiation tx delivery imrt
HCPCS
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48 CODE REFERENCEThis may not be a comp...
G6016
PR DELIVERY COMP IMRT
HCPCS
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/25/2015: Medical policy revised to add ICD-10 codes. Added ICD-9 diagnosis code range 190.0 - 190.9 to the Code Reference section. SOURCESBlue Cross & Blue Shield Association policy # 8.01.48 CODE REFERENCEThis may not be a comp...
1745
Thoracoscopic robotic assisted procedure
ICD
The Monmouth and Ocean County breast cancer death rate in the past two decades was 20.1% above the U.S., but 4.5% below for all causes other than cancer (Table 5). These differences are consistent for young, middle-aged, and older women. Mortality, Monmouth/Ocean Counties vs. U.S. From Cancer and From All Other Causes,...
1745
Thoracoscopic robotic assisted procedure
ICD
These differences are consistent for young, middle-aged, and older women. Mortality, Monmouth/Ocean Counties vs. U.S. From Cancer and From All Other Causes, 1985-2003 |All Cancers||Cancer||% Local is +/- U.S.| |Age 0-14||133||+13.4||– 31.7| |Age 15-44||1745||+12.0||– 16.4| |All- Whites||51430||+10.7||– 3.8| |All- Black...
1745
Thoracoscopic robotic assisted procedure
ICD
Mortality, Monmouth/Ocean Counties vs. U.S. From Cancer and From All Other Causes, 1985-2003 |All Cancers||Cancer||% Local is +/- U.S.| |Age 0-14||133||+13.4||– 31.7| |Age 15-44||1745||+12.0||– 16.4| |All- Whites||51430||+10.7||– 3.8| |All- Blacks||2478||+ 5.3||+ 0.4| |Breast Cancer (white females)| |Age 25-44||263||+1...
S9345
HIT anti-hemophil diem
HCPCS
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by ...
36440
PR PUSH TRANSFUSION BLOOD 2 YR OR YOUNGER
HCPCS
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by ...
85244
HC CLOTTING; FACTOR VIII (AHG) RELATED ANTIGEN
HCPCS
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by ...
1999
ANESTHESIOLOGY GROUP
CPT
The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by ...
S9345
HIT anti-hemophil diem
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee 1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one p...
36440
PR PUSH TRANSFUSION BLOOD 2 YR OR YOUNGER
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee 1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one p...
85244
HC CLOTTING; FACTOR VIII (AHG) RELATED ANTIGEN
HCPCS
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee 1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one p...
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. 4/1999: Approved by Pharmacy & Therapeutics (P & T) Oncology Committee 1/30/2002: Factor VIII (Human), Factor VIII (Recombinant) and Factor VIII (Porcine) policies combined into one p...
Q2023
Xyntha - inj
CPT
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint ...
Q2023
Xyntha - inj
CPT
BCBSMS information added. 6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint damage in children (0-16) with hemophilia A with no pre-exis...
Q2023
Xyntha - inj
CPT
6/30/2009: New HCPC code Q2023 added to covered table. 8/26/2009: Policy statement updated to include medically necessary indications for VIII for routine prophylaxis to reduce the frequency of bleeding episodes and the risk of joint damage in children (0-16) with hemophilia A with no pre-existing joint damage. 12/15/2...
J7185
Xyntha inj
HCPCS
Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy titl...
J7187
Injection, von willebrand factor complex (humate-p), per iu vwf:rco
HCPCS
Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy titl...
J7184
Wilate injection
HCPCS
Policy Section updated with coverage for Von Willebrand disease for Factor VIII. Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy titl...
J7185
Xyntha inj
HCPCS
Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor I...
J7187
Injection, von willebrand factor complex (humate-p), per iu vwf:rco
HCPCS
Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor I...
J7184
Wilate injection
HCPCS
Policy Exceptions Section updated to remove Risk Pool language. HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor I...
J7185
Xyntha inj
HCPCS
HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Fact...
J7187
Injection, von willebrand factor complex (humate-p), per iu vwf:rco
HCPCS
HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Fact...
J7184
Wilate injection
HCPCS
HCPCS code J7185 & J7187 were added to Covered Codes for Factor VIII. 02/28/2011: Added new HCPCS code J7184 for Wilate® to the Code Reference section. 04/01/2014: Policy title changed from "Hemophilia Factor VIII (Human, Recombinant, Porcine) and Factor IX (Human, Complex, Recombinant)" to "Hemophilia Factor VIII Fact...
J7182
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu
HCPCS
Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code f...
J7200
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
HCPCS
Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code f...
J7201
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
HCPCS
Policy description and FDA Approved Indications for Factors VIII and IX were updated. Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code f...
J7195
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified
HCPCS
Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPC...
J7182
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu
HCPCS
Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPC...
J7200
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
HCPCS
Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPC...
J7201
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
HCPCS
Policy statement updated to include "Factor VIII Deficiency" and "Hemophilia B" in medically necessary statements. Removed deleted HCPCS code Q2023 from the Code Reference section. 12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPC...
J7195
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified
HCPCS
12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the b...
J7182
Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iu
HCPCS
12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the b...
J7200
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
HCPCS
12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the b...
J7201
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
HCPCS
12/31/2014: Added the following new 2015 HCPCS code for Factor VIII to the Code Reference section: J7182. Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the b...
J7195
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified
HCPCS
Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: C...
J7200
Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iu
HCPCS
Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: C...
J7201
Injection, factor ix, fc fusion protein, (recombinant), alprolix, 1 i.u.
HCPCS
Added the following new 2015 HCPCS codes for Factor IX to the Code Reference section: J7200 and J7201. Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: C...
J7184
Wilate injection
HCPCS
Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286...
J7195
Injection, factor ix (antihemophilic factor, recombinant) per iu, not otherwise specified
HCPCS
Revised the description of the following HCPCS code: J7195. 05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286...
J7184
Wilate injection
HCPCS
05/28/2015: Policy description updated to add the brand name Eloctate® for Factor VIII (recombinant) and Alprolix® for Factor IX (recombinant). 08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: ...
J7184
Wilate injection
HCPCS
08/28/2015: Code Reference section updated for ICD-10. Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: Policy description updated to add the brand name Nuwiq® for Factor VIII (recombinant) and brand names Rixibus® and Ixinity® for Factor IX (recom...
J7184
Wilate injection
HCPCS
Extended ICD-9 diagnosis code 286.5 to the fifth digit as 286.52 - 286.59. Removed deleted HCPCS code J7184. 03/01/2016: Policy description updated to add the brand name Nuwiq® for Factor VIII (recombinant) and brand names Rixibus® and Ixinity® for Factor IX (recombinant). Policy statement unchanged. Policy guidelines ...
E0755
Electronic salivary reflex s
HCPCS
There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjogren's syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. |CPT Codes / H...
E0755
Electronic salivary reflex s
HCPCS
Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation. |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 "+":| |I...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
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...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
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...
61548
Removal of pituitary gland
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...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
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...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
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...
G0340
Robt lin-radsurg fractx 2-5
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...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
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...
G0339
Robot lin-radsurg com, first
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...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
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...
S8030
Tantalum ring application
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...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
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...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
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...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
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...