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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...
88384
Eval molecular probes 11-50
CPT
Neither CancerType ID® nor miRview® (or Rosetta Cancer Origin™) have been submitted to FDA for approval. Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor. Effective in July 2013, there is a specific ...
88384
Eval molecular probes 11-50
CPT
Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor. Effective in July 2013, there is a specific CPT coding for the Pathwork Tissue of Origin test: 81504 - Oncology (tissue of origin), microarray gene e...
81599
Unlisted multianalyte assay with algorithmic analysis
CPT
Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor. Effective in July 2013, there is a specific CPT coding for the Pathwork Tissue of Origin test: 81504 - Oncology (tissue of origin), microarray gene e...
88384
Eval molecular probes 11-50
CPT
Effective in July 2013, there is a specific CPT coding for the Pathwork Tissue of Origin test: 81504 - Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores Prior to July 2013, the preparation ...
81599
Unlisted multianalyte assay with algorithmic analysis
CPT
Effective in July 2013, there is a specific CPT coding for the Pathwork Tissue of Origin test: 81504 - Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores Prior to July 2013, the preparation ...
81599
Unlisted multianalyte assay with algorithmic analysis
CPT
Prior to July 2013, Pathwork Diagnostics stated that they used 84999 (unlisted chemistry procedure). The other tests described below do not have specific CPT codes. If the test result is calculated using an algorithm and reported as a numeric score(s) or as a probability, the unlisted multianalyte assays with algorithm...
81599
Unlisted multianalyte assay with algorithmic analysis
CPT
The other tests described below do not have specific CPT codes. If the test result is calculated using an algorithm and reported as a numeric score(s) or as a probability, the unlisted multianalyte assays with algorithmic analyses code 81599 would be reported. If not, the unlisted molecular pathology code 81479 would b...
90850
nan
CPT
Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. Sep 2011;22 Suppl 6:vi64-68. PMID 21908507 |CPT||81504||Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm re...
90850
nan
CPT
Ann Oncol. Sep 2011;22 Suppl 6:vi64-68. PMID 21908507 |CPT||81504||Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores| |ICD-9 Diagnosis||Investigational for all codes| |ICD-10-CM (effective ...
90850
nan
CPT
Sep 2011;22 Suppl 6:vi64-68. PMID 21908507 |CPT||81504||Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores| |ICD-9 Diagnosis||Investigational for all codes| |ICD-10-CM (effective 10/1/15)||I...
90850
nan
CPT
PMID 21908507 |CPT||81504||Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores| |ICD-9 Diagnosis||Investigational for all codes| |ICD-10-CM (effective 10/1/15)||Investigational for all releva...
55289-211-60
METFORMIN HCL 500 MG PO TAB
NDC
Answers to the “quiz” Code Source Term 1. 55454-3 LOINC Hemoglobin A1C 2. 250.02 ICD-9-CM Diabetes Mellitus without complications 3. E11.9 ICD-10-CM Type 2 Diabetes Mellitus without Complications 4. 55289-211-60 NDC GLUCOPHAGE 500 MG TABLET [PD-RX PHARM 60ea F/C] 5.
55289-211-60
METFORMIN HCL 500 MG PO TAB
NDC
55454-3 LOINC Hemoglobin A1C 2. 250.02 ICD-9-CM Diabetes Mellitus without complications 3. E11.9 ICD-10-CM Type 2 Diabetes Mellitus without Complications 4. 55289-211-60 NDC GLUCOPHAGE 500 MG TABLET [PD-RX PHARM 60ea F/C] 5. 3E013VG ICD-10-PCS Intro of Insulin into SubQ Tissue, Percutaneous Approach 6.
55289-211-60
METFORMIN HCL 500 MG PO TAB
NDC
250.02 ICD-9-CM Diabetes Mellitus without complications 3. E11.9 ICD-10-CM Type 2 Diabetes Mellitus without Complications 4. 55289-211-60 NDC GLUCOPHAGE 500 MG TABLET [PD-RX PHARM 60ea F/C] 5. 3E013VG ICD-10-PCS Intro of Insulin into SubQ Tissue, Percutaneous Approach 6. 1-800-783-3637 US Phone Stanley Steemer (1-800-S...
55289-211-60
METFORMIN HCL 500 MG PO TAB
NDC
E11.9 ICD-10-CM Type 2 Diabetes Mellitus without Complications 4. 55289-211-60 NDC GLUCOPHAGE 500 MG TABLET [PD-RX PHARM 60ea F/C] 5. 3E013VG ICD-10-PCS Intro of Insulin into SubQ Tissue, Percutaneous Approach 6. 1-800-783-3637 US Phone Stanley Steemer (1-800-STEEMER) (go ahead... sing the rest)
55289-211-60
METFORMIN HCL 500 MG PO TAB
NDC
55289-211-60 NDC GLUCOPHAGE 500 MG TABLET [PD-RX PHARM 60ea F/C] 5. 3E013VG ICD-10-PCS Intro of Insulin into SubQ Tissue, Percutaneous Approach 6. 1-800-783-3637 US Phone Stanley Steemer (1-800-STEEMER) (go ahead... sing the rest)
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...
61795
Brain surgery using computer
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...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
61548
Removal of pituitary gland
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
G0340
Robt lin-radsurg fractx 2-5
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
G0339
Robot lin-radsurg com, first
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
S8030
Tantalum ring application
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
61795
Brain surgery using computer
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 HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton ...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
61548
Removal of pituitary gland
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
1996
Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
G0339
Robot lin-radsurg com, first
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
S8030
Tantalum ring application
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
61795
Brain surgery using computer
HCPCS
POLICY HISTORY9/1992: Approved by Medical Policy Advisory Committee (MPAC) 9/1994: Reviewed and updated by MPAC 10/1996: Reviewed and updated by MPAC 2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary...
31254
PR NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31294
PR NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
61548
Removal of pituitary gland
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31288
PR NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
G0340
Robt lin-radsurg fractx 2-5
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31287
PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
G0339
Robot lin-radsurg com, first
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31276
PR NASAL/SINUS NDSC W/RMVL TISS FROM FRONTAL SINUS
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
S8030
Tantalum ring application
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31290
PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31256
PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
31267
PR NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...
61795
Brain surgery using computer
HCPCS
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication 2/13/2002: Investigational definition added 3/5/2002: Prior authorization added 3/12/2002: New 2002 codes added 5/8/2002: Type of Service and Place of Service deleted 9/20/2002: Policy reviewed, Hayes report number added 12/4/20...