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943 | Other Therapeutic Services Cardiac Rehabilitation | RC | Retrieved 2011-01-11. - ^ Carpentier S, Knaus M, Suh M (2009). "Associations between lutein, zeaxanthin, and age-related macular degeneration: An overview". Critical reviews in Food Science and Nutrition 49 (4): 313–326. doi:10.1080/10408390802066979. PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). |
0206 | HC INTERMEDIATE ROOM AND CARE ISOLATION | RC | - ^ Carpentier S, Knaus M, Suh M (2009). "Associations between lutein, zeaxanthin, and age-related macular degeneration: An overview". Critical reviews in Food Science and Nutrition 49 (4): 313–326. doi:10.1080/10408390802066979. PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". |
0839 | Peritoneal Dialysis - Outpatient or Home - Other Outpatient Peritoneal Dialysis | RC | - ^ Carpentier S, Knaus M, Suh M (2009). "Associations between lutein, zeaxanthin, and age-related macular degeneration: An overview". Critical reviews in Food Science and Nutrition 49 (4): 313–326. doi:10.1080/10408390802066979. PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". |
0802 | Inpatient Renal Dialysis - Inpatient Peritoneal (Non-CAPPD) | RC | - ^ Carpentier S, Knaus M, Suh M (2009). "Associations between lutein, zeaxanthin, and age-related macular degeneration: An overview". Critical reviews in Food Science and Nutrition 49 (4): 313–326. doi:10.1080/10408390802066979. PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". |
943 | Other Therapeutic Services Cardiac Rehabilitation | RC | - ^ Carpentier S, Knaus M, Suh M (2009). "Associations between lutein, zeaxanthin, and age-related macular degeneration: An overview". Critical reviews in Food Science and Nutrition 49 (4): 313–326. doi:10.1080/10408390802066979. PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". |
997 | HC MAINTENANCE PULMONARY REHAB | RC | PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". Br J Ophthalmol 93 (9): 1241–6. doi:10.1136/bjo.2008.143412. PMC 3033729. PMID 19508997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3033729. |
341 | Nuclear Medicine Diagnostic | RC | PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". Br J Ophthalmol 93 (9): 1241–6. doi:10.1136/bjo.2008.143412. PMC 3033729. PMID 19508997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3033729. |
943 | Other Therapeutic Services Cardiac Rehabilitation | RC | PMID 19234943. "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". Br J Ophthalmol 93 (9): 1241–6. doi:10.1136/bjo.2008.143412. PMC 3033729. PMID 19508997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3033729. |
997 | HC MAINTENANCE PULMONARY REHAB | RC | "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". Br J Ophthalmol 93 (9): 1241–6. doi:10.1136/bjo.2008.143412. PMC 3033729. PMID 19508997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3033729. "Conclusions: The findings show an association of consuming a diet rich in DHA with a lower progression of early AMD. |
341 | Nuclear Medicine Diagnostic | RC | "Abstract doesnt include conclusion"
- ^ Chiu CJ, Klein R, Milton RC, Gensler G, Taylor A (June 2009). "Does eating particular diets alter the risk of age-related macular degeneration in users of the Age-Related Eye Disease Study supplements?". Br J Ophthalmol 93 (9): 1241–6. doi:10.1136/bjo.2008.143412. PMC 3033729. PMID 19508997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3033729. "Conclusions: The findings show an association of consuming a diet rich in DHA with a lower progression of early AMD. |
G0400 | PR HOME SLEEP TEST/TYPE 4 PORTA | HCPCS | An HSAT is a preference for many patients since they can take the test at home in a more natural, relaxing and private environment that is also more likely to reflect the actual disease manifestation. Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). |
G0398 | PR HOME SLEEP TEST/TYPE 2 PORTA | HCPCS | An HSAT is a preference for many patients since they can take the test at home in a more natural, relaxing and private environment that is also more likely to reflect the actual disease manifestation. Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). |
G0399 | PR HOME SLEEP TEST/TYPE 3 PORTA | HCPCS | An HSAT is a preference for many patients since they can take the test at home in a more natural, relaxing and private environment that is also more likely to reflect the actual disease manifestation. Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | An HSAT is a preference for many patients since they can take the test at home in a more natural, relaxing and private environment that is also more likely to reflect the actual disease manifestation. Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). |
G0400 | PR HOME SLEEP TEST/TYPE 4 PORTA | HCPCS | Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. |
G0398 | PR HOME SLEEP TEST/TYPE 2 PORTA | HCPCS | Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. |
G0399 | PR HOME SLEEP TEST/TYPE 3 PORTA | HCPCS | Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Today, the vast majority of payers reimburse for HSAT and some recommend it as a first-line diagnosis for sleep apnea. However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. |
G0400 | PR HOME SLEEP TEST/TYPE 4 PORTA | HCPCS | However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. |
G0398 | PR HOME SLEEP TEST/TYPE 2 PORTA | HCPCS | However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. |
G0399 | PR HOME SLEEP TEST/TYPE 3 PORTA | HCPCS | However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | However, coding and billing requirements differ from payer to payer. This article will outline some of the basics, but it is always best to check with your payer for their specific requirements With a few exceptions, licensed medical doctors, regardless of their specialty, can prescribe HSAT to patients who are suspected of having sleep apnea based on signs and symptoms and testing positive for high risk on validated instruments such as the STOP-BANG, Epworth Sleepiness, and DOISNORE 50 questionnaires. Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. |
G0400 | PR HOME SLEEP TEST/TYPE 4 PORTA | HCPCS | Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. |
G0398 | PR HOME SLEEP TEST/TYPE 2 PORTA | HCPCS | Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. |
G0399 | PR HOME SLEEP TEST/TYPE 3 PORTA | HCPCS | Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Physicians may also consider clinical symptoms such as atrial fibrillation and hypertension as signs for high pre-test probability, based on the most recent AASM guidelines.1
HST G CODES AND CPT CODES
In 2007 the AASM published the “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.”2 which differentiated the HSATs by type (defined by the AASM). In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. |
G0398 | PR HOME SLEEP TEST/TYPE 2 PORTA | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
G0400 | PR HOME SLEEP TEST/TYPE 4 PORTA | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
95800 | Slp stdy unattended | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
G0399 | PR HOME SLEEP TEST/TYPE 3 PORTA | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
95801 | Slp stdy unatnd w/anal | HCPCS | In the following year, Medicare introduced the HCPCS Level II codes G0398, G0399, and G0400 which followed the AASM types. G codes are “carrier determined,” which means that payment is up to the discretion of the Medicare Administrative Contractors (MACs). G CODES / SLEEP TYPE CLASSIFICATION
G0398 Home sleep study with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation. G0399 Home sleep study with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation. G0400 Home sleep study with type IV portable monitor, unattended; minimum of 3 channels. In 2009, Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) which included the WatchPAT® as a covered test. Today, most CMS MACs request the use of G codes to report HSATs and request the use of G0400 to report WatchPAT.3
In 2011, the AMA added the CPT codes 95800 and 95801 to describe HSAT using peripheral arterial tone (i.e. |
451 | Emergency Room EMTALA Emergency Medical Screening | RC | (Kaushal S, et al IOVS 2009;50:ARVO e-abstract 5010.) It is currently in Phase II clinical trials. • ARC1905 (Ophthotech, New York, N.Y.) is an aptamer-based C5 inhibitor, blocking the cleavage of C5 into C5a and C5b fragments and is another intravitreally administered complement inhibitor being evaluated in AMD. Like POT-4, it is similarly selective for a centrally positioned component within the cascade, although exerting its effect further downstream. • FCFD4514S (Genentech) is an anti-factor D antibody being studied for the treatment of dry AMD. Blockage of the complement factors (such as factor D) that moderate the production of these end-products serves to attenuate complement activation, rather than shutting the system down completely. Anti-factor D is administered intravitreously and selectively inhibits CFD which is a key component of the amplification step of the alternatve pathway. |
A4595 | TENS suppl 2 lead per month | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. |
A4595 | TENS suppl 2 lead per month | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. |
A4595 | TENS suppl 2 lead per month | HCPCS | POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | POLICY HISTORY5/1998: Approved by Medical Policy Advisory Committee (MPAC) as part of comprehensive Physical Medicine policy
3/29/2000: Excerpted from Physical Medicine policy with clarifications
2/13/2002: Investigational definition added, Managed Care Requirements deleted, coding statement added to Code Reference section
5/2/2002: Type of Service and Place of Service deleted
8/19/2002: Hyperlinks deleted
10/18/2005: Code Reference section updated; "A diagnosis code(s) must be linked to one of the following HCPCS and/or CPT Procedure Code. All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. |
720 | Vaginal Delivery - Multiple Fetus | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
721 | Labor Room/Delivery Labor | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
342 | Nuclear Medicine Therapeutic | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
0731 | EKG/ecg (Electrocardiogram) - Holter Monitor | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
924 | Other Diagnostic Services Allergy Test | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
A4595 | TENS suppl 2 lead per month | HCPCS | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
731 | EKG/ECG (Electrocardiogram) Holter Monitor | RC | All other diagnosis codes are not covered." deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. |
720 | Vaginal Delivery - Multiple Fetus | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
721 | Labor Room/Delivery Labor | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
342 | Nuclear Medicine Therapeutic | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
0731 | EKG/ecg (Electrocardiogram) - Holter Monitor | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
924 | Other Diagnostic Services Allergy Test | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
A4595 | TENS suppl 2 lead per month | HCPCS | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
E0731 | Form fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient''s skin by layers of fabric) | HCPCS | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
731 | EKG/ECG (Electrocardiogram) Holter Monitor | RC | deleted; ICD-9 Diagnosis: V54.01, V54.02, V54.09, V54.81, V54.89, 728.2 added: 274.0, 333.83, 723.5, 337.20-337.29, 342.00-342.92, 353.1, 354.0-354.8, 355.0-355.8, 457.0, 729.81, 782.3, 711.00-716.59, 718.20-718.49, 719.00-719.59, 720.0-720.89, 721.0-723.5, 724.01-724.79, 726.0-726.67, 727.81-728.11, 728.12, 728.2, 728.6, 728.71, 728.83, 728.85, 729.4, 729.5, 729.81-729.82, 782.3, 923.0-924.4 deleted; HCPCS: A4595, E0731 added
10/23/2006: Policy reviewed, no changes
9/30/2009: Code reference section updated. ICD-9 new diagnosis codes 813.46, 813.47 and 832.2 added to covered table. 09/01/2015: Code Reference section updated for ICD-10. 05/27/2016: Policy number L.8.03.401 added. 09/30/2016: Code Reference section updated to add the following new ICD-10 diagnoses: S03.00XA - S03.03XS, S03.40XA - S03.43XS, S99.001A - S99.001S, S99.002A - S99.002S, S99.009A - S99.009S, S99.011A - S99.011S, S99.021A - S99.021S, S99.031A - S99.031S, S99.041A - S99.041S, S99.091A - S99.091S, and S99.209D - S99.209S. SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. |
990 | Patient Convenience Items General Classification | RC | SOURCE(S)Cognitive Remediation in Traumatic Brain Injury: Update and Issues, Achieves of Physical Medicine and Rehabilitation, vol. 74, Feb. 1993, pp. 204-213. Guidelines for Cognitive Rehabilitation, NeuroRehabilitation, August, 1992, pp. 62-67. Published Trials of Nonmedical and Noninvasive Therapies for Hip and Knee Osteoarthritis, Annals of Internal Medicine, Physical Therapy, vol. 121, Number 2, May 1990, pp. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance. Revenue codes have not been identified for this procedure since it can be performed in a number of revenue centers within a hospital such as emergency room (450), operation room (360), or a clinic (510). Report this HCPCS codeunder the revenue center where it was performed. Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance. Revenue codes have not been identified for this procedure since it can be performed in a number of revenue centers within a hospital such as emergency room (450), operation room (360), or a clinic (510). Report this HCPCS codeunder the revenue center where it was performed. Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | 100-04, Claims Processing Manual, for further guidance. Revenue codes have not been identified for this procedure since it can be performed in a number of revenue centers within a hospital such as emergency room (450), operation room (360), or a clinic (510). Report this HCPCS codeunder the revenue center where it was performed. Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. |
93701 | PR BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS | HCPCS | 100-04, Claims Processing Manual, for further guidance. Revenue codes have not been identified for this procedure since it can be performed in a number of revenue centers within a hospital such as emergency room (450), operation room (360), or a clinic (510). Report this HCPCS codeunder the revenue center where it was performed. Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. - Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. - The medical record must show that this modality contributed to the management of the patient The use of bioimpedance must be supported by documented changes in the clinical examination and provide for a level of clinical decision-making beyond the findings of the history and physical examination. |
93701 | PR BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS | HCPCS | Providers are reminded to refer to the long descriptors of the
Bioimpedance, cv analysis
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. - Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. - The medical record must show that this modality contributed to the management of the patient The use of bioimpedance must be supported by documented changes in the clinical examination and provide for a level of clinical decision-making beyond the findings of the history and physical examination. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. - Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. - The medical record must show that this modality contributed to the management of the patient The use of bioimpedance must be supported by documented changes in the clinical examination and provide for a level of clinical decision-making beyond the findings of the history and physical examination. - A separate report, i.e., separate from the Evaluation and Management (E/M) service documentation, should be available for review. |
93701 | PR BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS | HCPCS | The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Hypertrophic obstructive cardiomyopathy
Other primary cardiomyopathies
Secondary cardiomyopathy, unspecified
Congestive heart failure, Unspecified
Left heart failure
Systolic Heart Failure
Diastolic Heart Failure
Combined systolic and diastolic heart failure
Heart failure, unspecified
Shortness of breath
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Diagnoses That Support Medical Necessity
ICD-9-CM Codes That DO NOT Support Medical Necessity
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. - Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. - The medical record must show that this modality contributed to the management of the patient The use of bioimpedance must be supported by documented changes in the clinical examination and provide for a level of clinical decision-making beyond the findings of the history and physical examination. - A separate report, i.e., separate from the Evaluation and Management (E/M) service documentation, should be available for review. |
87475 | Lyme dis dna dir probe | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87477 | Lyme dis dna quant | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87476 | LYME DISEASE PCR | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
87475 | Lyme dis dna dir probe | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87477 | Lyme dis dna quant | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87476 | LYME DISEASE PCR | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. |
87477 | Lyme dis dna quant | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87476 | LYME DISEASE PCR | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87475 | Lyme dis dna dir probe | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0540 | Penicillin g benzathine inj | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0550 | Penicillin g benzathine inj | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
J0530 | Penicillin g benzathine inj | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. |
87477 | Lyme dis dna quant | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
87476 | LYME DISEASE PCR | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
87475 | Lyme dis dna dir probe | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
J0540 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
J0550 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
J0530 | Penicillin g benzathine inj | HCPCS | POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. |
J0540 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0550 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0530 | Penicillin g benzathine inj | HCPCS | Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes. 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. |
J0540 | Penicillin g benzathine inj | HCPCS | 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
J0550 | Penicillin g benzathine inj | HCPCS | 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
. | Albumin VIAL 5% 12.5g/250 mL | HCPCS | 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
J0530 | Penicillin g benzathine inj | HCPCS | 12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment. It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. |
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