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code stringlengths 4 12	description stringlengths 2 264	codetype stringclasses 8 values	context stringlengths 160 15.5k
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; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
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; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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, 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 96445 and replaced with CPT code 96446. SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.31 CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
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 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 of the probes might have been coded using a combination of the molecular diagnostic codes 83890-83913 and the analysis of the probes might have been coded using array-based evaluation of multiple molecular probes codes 88384-88386 based on the number of probes analyzed. 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.
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 expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores Prior to July 2013, the preparation of the probes might have been coded using a combination of the molecular diagnostic codes 83890-83913 and the analysis of the probes might have been coded using array-based evaluation of multiple molecular probes codes 88384-88386 based on the number of probes analyzed. 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 algorithmic analyses code 81599 would be reported.
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 expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores Prior to July 2013, the preparation of the probes might have been coded using a combination of the molecular diagnostic codes 83890-83913 and the analysis of the probes might have been coded using array-based evaluation of multiple molecular probes codes 88384-88386 based on the number of probes analyzed. 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 algorithmic analyses code 81599 would be reported.
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 of the probes might have been coded using a combination of the molecular diagnostic codes 83890-83913 and the analysis of the probes might have been coded using array-based evaluation of multiple molecular probes codes 88384-88386 based on the number of probes analyzed. 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 algorithmic analyses code 81599 would be reported. If not, the unlisted molecular pathology code 81479 would be reported.
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 of the probes might have been coded using a combination of the molecular diagnostic codes 83890-83913 and the analysis of the probes might have been coded using array-based evaluation of multiple molecular probes codes 88384-88386 based on the number of probes analyzed. 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 algorithmic analyses code 81599 would be reported. If not, the unlisted molecular pathology code 81479 would be reported.
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 algorithmic analyses code 81599 would be reported. If not, the unlisted molecular pathology code 81479 would be reported. BlueCard/National Account Issues State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
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 be reported. BlueCard/National Account Issues State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity. This policy was created in December 2008 and has been updated annually.
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 reported as tissue similarity scores\| \|ICD-9 Diagnosis\|\|Investigational for all codes\| \|ICD-10-CM (effective 10/1/15)\|\|Investigational for all relevant diagnoses\| \|C79.9\|\|Secondary malignant neoplasm of unspecified site\| \|C80.0\|\|Disseminated malignant neoplasm, unspecified\| \|C80.1\|\|Malignant (primary) neoplasm, unspecified\| \|ICD-10-PCS (effective 10/1/15)\|\|Not applicable. ICD-10-PCS codes are only used for inpatient services.
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 10/1/15)\|\|Investigational for all relevant diagnoses\| \|C79.9\|\|Secondary malignant neoplasm of unspecified site\| \|C80.0\|\|Disseminated malignant neoplasm, unspecified\| \|C80.1\|\|Malignant (primary) neoplasm, unspecified\| \|ICD-10-PCS (effective 10/1/15)\|\|Not applicable. ICD-10-PCS codes are only used for inpatient services. There are no ICD procedure codes for laboratory tests.\| \|Type of Service\|\|Pathology/Laboratory\| \|Place of Service\|\|Laboratory/Reference Laboratory\| Pathwork Tissue of Unknown Origin Add to Medicine section \|12/03/09\|\|Replace policy\|\|Policy updated with literature search; reference 12 added, reference 13 updated.
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)\|\|Investigational for all relevant diagnoses\| \|C79.9\|\|Secondary malignant neoplasm of unspecified site\| \|C80.0\|\|Disseminated malignant neoplasm, unspecified\| \|C80.1\|\|Malignant (primary) neoplasm, unspecified\| \|ICD-10-PCS (effective 10/1/15)\|\|Not applicable. ICD-10-PCS codes are only used for inpatient services. There are no ICD procedure codes for laboratory tests.\| \|Type of Service\|\|Pathology/Laboratory\| \|Place of Service\|\|Laboratory/Reference Laboratory\| Pathwork Tissue of Unknown Origin Add to Medicine section \|12/03/09\|\|Replace policy\|\|Policy updated with literature search; reference 12 added, reference 13 updated. No change to policy statement\| \|11/11/10\|\|Replace policy\|\|Policy updated with literature search; reference 12 added, reference 1 and 13 updated; new test for formalin-fixed paraffin-embedded (FFPE) specimens added as investigational, no change to existing policy statement\| \|11/10/11\|\|Replace policy\|\|Policy updated with literature search; references 11, 12 and 14 added.
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 relevant diagnoses\| \|C79.9\|\|Secondary malignant neoplasm of unspecified site\| \|C80.0\|\|Disseminated malignant neoplasm, unspecified\| \|C80.1\|\|Malignant (primary) neoplasm, unspecified\| \|ICD-10-PCS (effective 10/1/15)\|\|Not applicable. ICD-10-PCS codes are only used for inpatient services. There are no ICD procedure codes for laboratory tests.\| \|Type of Service\|\|Pathology/Laboratory\| \|Place of Service\|\|Laboratory/Reference Laboratory\| Pathwork Tissue of Unknown Origin Add to Medicine section \|12/03/09\|\|Replace policy\|\|Policy updated with literature search; reference 12 added, reference 13 updated. No change to policy statement\| \|11/11/10\|\|Replace policy\|\|Policy updated with literature search; reference 12 added, reference 1 and 13 updated; new test for formalin-fixed paraffin-embedded (FFPE) specimens added as investigational, no change to existing policy statement\| \|11/10/11\|\|Replace policy\|\|Policy updated with literature search; references 11, 12 and 14 added. No change to policy statement.\| \|11/08/12\|\|Replace policy\|\|Policy updated with literature search; references 14- 21 added.
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-STEEMER) (go ahead... sing the rest)
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 and as such therefore is not considered 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. 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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 beam therapy for prostate cancer considered investigational 4/3/2001: Code Reference updated 5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 for early stage, surgically inoperable non-small cell lung cancer. 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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.
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 12/4/2002: Hayes report number deleted 12/11/2002: HCPCS S8030 added 1/17/2003: Policy section updated 3/7/2003: Code Reference section updated 8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately 6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes 2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy"section for specific coverage of Stereotactic Radiosurgery 3/14/2006: Coding updated. HCPCS 2005 revisions added to policy 7/20/2006: Policy reviewed, prior authorization removed 8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added 9/5/2006: Code reference section udpated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted.

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