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Date Printed: August 22, 2017: 07:06 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-A0000-03

Original Effective Date: 01/01/03

Revised: 08/01/17

Subject: Investigational Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

         
Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
         
Other References Updates  
         

DESCRIPTION:

BCBSF uses the following five process/decision variables set forth by the Blue Cross Blue Shield Association for evaluation and assessment of new technologies and applications of existing technologies:

  1. The technology must have final approval from the appropriate government regulatory bodies, for example, the U.S. Food and Drug Administration (FDA).
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
  3. The technology must improve the net health outcome.
  4. The technology must be as beneficial as any established alternatives.
  5. The improvement must be attainable outside the investigational setting.

For Medicare Advantage products, see the Program Exception section of this guideline.

The list below identifies procedures that do not meet the five process/decision variables listed above and are therefore considered experimental or investigational. This listing is not all-inclusive and any procedure or device that is not listed below or is not included in a medical coverage guideline and does not meet the five process/decision variables may be considered experimental or investigational.

Code

Descriptor/Narrative

S2103

Adrenal tissue transplant to brain

S8930

Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with patient

S9001

Home uterine monitor with or without associated nursing services

33265

Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass

33266

Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass

34806

Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data (List separately in addition to code for primary procedure)

43252

Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy

82610

Cystatin C

84145

Procalcitonin (PCT)

85384

Fibrinogen; activity

85385

Fibrinogen; antigen

86352

Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP)

91132

Electrogastrography, diagnostic, transcutaneous

91133

Electrogastrography, diagnostic, transcutaneous; with provocative testing

92145

Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report

93895

Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

93982

Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report

97610

Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day

0100T

Placement of a subconjunctival retinal prosthesis receiver and pulse generator and implantation of intraocular retinal electrode array, with vitrectomy

0126T

Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment

0178T

Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report

0179T

Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and graphics only, w/o interpretation and report

0180T

Electrocardiogram, 64 leads or greater, interpretation and report only

0190T

Placement of intraocular radiation source applicator (List separately in addition to primary procedure)

0198T

Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report

0205T

Intravascular catheter-based coronary vessel or graft spectroscopy (e.g., infrared) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation, and report, each vessel (List separately in addition to code for primary procedure)

0208T

Pure tone audiometry (threshold), automated (includes use of computer assisted device); air only

0209T

Pure tone audiometry (threshold), automated (includes use of computer assisted device); air and bone

0210T

Speech audiometry threshold, automated (includes use of computer assisted device)

0211T

Speech audiometry threshold, automated (includes use of computer assisted device): with speech recognition

0212T

Comprehensive audiometry threshold evaluation and speech recognition (0209T , 0211T combined), automated (includes use of computer assisted device)

0219T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices (s), single level; cervical

0220T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices (s), single level; thoracic

0221T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices (s), single level; lumbar

0222T

Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic devices (s), each additional vertebral segment (List separately in addition to code for primary procedure)

0263T

Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest

0264T

Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest

0265T

Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy

0266T

Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed)

0267T

Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed)

0268T

Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)

0269T

Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed)

0270T

Revision or removal of carotid sinus baroreflex activation device; lead only (includes intra-operative interrogation, programming, and repositioning, when performed)

0271T

Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed)

0272T

Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day)

0273T

Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) with programming

0278T

Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)

0293T

Insertion of left atrial hemodynamic monitor; complete system, includes implanted communication module and pressure sensor lead in left atrium including transseptal access, radiological supervision and interpretation, and associated injection procedures, when performed

0294T

pressure sensor lead at time of insertion of pacing cardioverter-defibrillator pulse generator including radiological supervision and interpretation and associated injection procedures, when performed (List separately in addition to code for primary procedure)

0299T

Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound

0300T

Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure)

0302T

Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system (includes device and electrode)

0303T

Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system, electrode only

0304T

Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system, device only

0305T

Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report

0306T

Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report

0307T

Removal of intracardiac ischemia monitoring device

0308T

Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis

0329T

Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report

0330T

Tear film imaging, unilateral or bilateral, with interpretation and report

0331T

Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment

0332T

Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT

0337T

Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral

0338T

Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral

0339T

Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral

0346T

Ultrasound, elastography (List separately in addition to code for primary procedure)

0347T

Placement of interstitial device(s) in bone for radiostereometric analysis (RSA)

0348T

Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed)

0349T

Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed)

0350T

Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed)

0351T

Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative

0352T

Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred

0353T

Optical coherence tomography of breast, surgical cavity; real time intraoperative

0354T

Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred

0356T

Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each

0381T

External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0382T

External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional; review and interpretation only

0383T

External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0384T

External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional; review and interpretation only

0385T

External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0386T

External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional; review and interpretation only

0387T

Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular

0388T

Transcatheter removal of permanent leadless pacemaker, ventricular

0389T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system

0390T

Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

0391T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

0396T

Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary procedure)

0398T

Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed

0402T

Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

0408T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes

0409T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only

0410T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only

0411T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only

0412T

Removal of permanent cardiac contractility modulation system; pulse generator only

0413T

Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)

0414T

Removal and replacement of permanent cardiac contractility modulation system pulse generator only

0415T

Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead)

0416T

Relocation of skin pocket for implanted cardiac contractility modulation pulse generator

0417T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system

0418T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system

0421T

Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)

0422T

Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral

0423T

Secretory type II phospholipase A2 (sPLA2-IIA)

0424T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)

0425T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only

0426T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only

0427T

Insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only

0428T

Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only

0429T

Removal of neurostimulator system for treatment of central sleep apnea; sensing lead only

0430T

Removal of neurostimulator system for treatment of central sleep apnea; stimulation lead only

0431T

Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only

0432T

Repositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only

0433T

Repositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only

0434T

Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea

0435T

Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session

0436T

Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study

0443T

Real time spectral analysis of prostate tissue by fluorescence spectroscopy

0444T

Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral

0445T

Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral

0466T

Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure)

0467T

Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator

0468T

Removal of chest wall respiratory sensor electrode or electrode array

0470T

Optical coherence tomography (OCT) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; first lesion

0471T

Optical coherence tomography (OCT) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; each additional lesion (List separately in addition to code for primary procedure)

0006U

Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service

0011U

Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites

Complementary or alternative medicine diagnostic testing is considered experimental or investigational as there is insufficient clinical evidence to support the use of this testing for all indications.

BILLING/CODING INFORMATION:

“S” codes are developed by Blue Cross/Blue Shield and other commercial payers to report drugs, services, and supplies. They may not be used to bill services paid under any Medicare payment program.

REIMBURSEMENT INFORMATION:

None applicable.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

National Coverage Determinations (NCDs) can be found at cms.gov.

Local Coverage Determinations (LCDs) can be found at fcso.com.

Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determinations (LCDs) can be found at cgsmedicare.com.

DEFINITIONS:

American Medical Association Category III Codes: Temporary codes for emerging technology, services, and procedures. The inclusion of a service or procedure in this code section neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice. The codes in this code section do not conform to the usual requirements for CPT Category I codes established by the CPT Editorial Panel. For Category I codes, the Panel requires that the service/procedure be performed by many health care professionals in clinical practice in multiple locations and the FDA approval, as appropriate, has already been received. The nature of emerging technology, services, and procedures is such that these requirements may not be met.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Medical Association CPT.
  2. Centers for Medicare & Medicaid Services (CMS), Medicare National Coverage Determinations (NCD) Online Manual located at cms.gov.
  3. CGS Administrators, LLC, Durable Medical Equipment Regional Carrier (DMERC), Local Coverage Determinations (LCDs) located at cgsmedicare.com.
  4. First Coast Service Options, Inc. (FCSO), Local Coverage Determinations (LCDs) located at fcso.com.
  5. St. Anthony HCPCS.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the Florida Blue Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

01/01/03

New Medical Coverage Guideline (MCG) documenting existing BCBSF investigational services and new 2003 CPT Codes.

02/15/03

CPT Codes 73542, 93720, 93721, 93722, 94014, 94015, and 94016, E0761, G0251, G0252, G0253, G0254, G0255, G0279, G0280, S1040, and S3650 was added for consistency with existing coverage. Unlisted services: In vitro chemoresistance and chemosensitivity, Partial left ventriculectomy, Sensory stimulation for coma patients, and Ultrasound spine scan added for consistency with existing coverage. CPT Codes 96000, 96001, 96002, 96003, and 96004 coverage changed from non-covered to investigational. Investigational status deleted for code S8040 and the following Unlisted services: Cranial Electrotherapy Stimulation, and Tidal Knee irrigation.

04/01/03

Added: 76800, K0600, S2103, and S2300 (HCPCS update).

08/15/03

Added: 43843, 43847, A4639, E0221, S2090, S2091, S3852, V5095, and 0045T.
Deleted: 32655, 48160, 52327, 65760, 65765, and 65771, G0185, G0187, S2112, and S8049.

09/15/03

Added: K0606, K0607, K0608, and K0609.

10/01/03

Added: S2230.

10/15/03

Added: S2213, S9476.
Deleted: 43847, 72159, 72198, and 73225, S8915, S8916, and S8917.

11/15/03

Added: G0296.
Deleted: G0252, G0253, G0254, and kyphoplasty (unlisted).

01/01/04

Annual HCPCS coding update: added 0054T, 0055T, 0056T, 0057T, 0058T, 0059T, 0060T, 0061T, G0302, G0303, G0304, and G0305.
Deleted: 0002T, kyphoplasty (unlisted).

02/15/04

Added: E0675
Deleted: 47370, 47380, and 47382.

03/15/04

Added: 20982
Deleted: herniography, intradialytic parenteral nutrition, intraperitoneal nutrition (unlisted).

05/15/04

Added: 0046T, and0047T.
Deleted: G0290, G0291, and G0296.

07/15/04

Deleted: 76800.

10/15/04

Added: 0051T, 0052T, 0053T, E0830, G0339, G0340, and S8948.
Deleted: 93784, 93786, 93788, and 93790.

12/15/04

Deleted: 73542, G0259, and G0260.

01/01/04

Annual HCPCS coding update: added 0062T, 0063T, 0064T, 0065T, 0066T, 0067T, 0068T, 0069T, 0070T, 0071T, 0072T, 0073T, 0075T, 0076T, 0077T, 0078T, 0079T, 0080T, 0081T, 0082T, 0083T, 0084T, 0085T, 0086T, 0087T, and 0088T.
Deleted: 0001T, 0005T, 0006T, 0007T, 0014T, and 0057T.
Revised: 0055T.

03/15/05

Added: L5856, and L5857.
Deleted: 20982, 86301, 93720, 93721, and 93722. Also, revision of unlisted code section, with transfer of appropriate items to code section.

06/15/05

Added: 43645, and 43845.
Deleted: 73725, and S9476.

07/01/05

HCPCS coding changes
Added: 0089T, 0090T, 0091T, 0092T, 0093T, 0094T, 0095T, 0096T, 0097T, 0098T, 0099T, 0100T, 0101T, 0102T, 0103T, 0104T, 0105T, 0106T, 0107T, 0108T, 0109T, 0110T, and 0111T.
Revised: 0019T, and 0078T.

09/15/05

Added: E0617, and 62287.

10/15/05

Added: E2120, G0282, G0295, K0670, S2082, S2083, S2215, S2348, S3890, S8940, 37215, 37216, 43257, 89251, 91035, 92625, and 93745.
Deleted: G0302, G0303, G0304, G0305, G0339, G0340, S2370, S2371, 32491, and 76390.

01/01/06

Annual HCPCS coding update: added: 0120T, 0123T, 0124T, 0126T, 0133T, 0135T, 0137T, 28890, 33548, 43770, 43771, 43772, 43773, 43774, 50250, 50592, 61630, 61635, 61640, 61641, 61642, 83695, 83701, 83704, 87900, 95251, E0762, and E0764.
Revised: 95250.
Deleted: 0020T, 0023T, 0033T, 0034T, 0035T, 0036T, 0037T, 0038T, 0039T, 0040T, G0279, G0280, K0600, K0670, S2082, S2090, S2091, S2215, and 83716.

02/15/06

Added: 0140T, 0144T, 0146T, 0147T, 0148T, 0149T, L5858, S3854, and 37500.
Deleted: 0099T, E0675, S9024, 47371, and 47381.

04/15/06

Deleted: 0078T, 0079T, 0080T, 0081T, 37500, 43770, 43771, 43772, 43773, 43774, 43845, E2120, and S8093.

05/15/06

Deleted: G0186, and S1040.

06/15/06

Added: 0145T, 0150T, 0151T, G0330, and G0331.
Deleted: K0606, K0607, K0608, K0609, 37215, 37216, 93745, 96920, 96921, and 96922.

07/15/06

Deleted: A4634, E0203, and 86141.

08/15/06

Deleted: S2083, and 91035.

09/15/06

Deleted: 0067T.

10/15/06

Deleted: S2205, S2206, S2207, S2208, and S2209.

11/15/06

Added S8190, 89346, and 89356.

01/01/07

Annual HCPCS coding update: added: 0153T, 0154T, 0166T, 0167T, 0168T, 0169T, 0170T, 0171T, 0172T, 0176T, 0177T, and S2344.
Deleted: All codes with associated MCGs.

07/01/07

HCPCS Update: added codes 0178T, 0179T, 0180T, 0181T, 0182T and S3905.

01/01/08

Annual HCPCS coding update: added 0183T, 0184T, 0186T, 0187T 34806, and 93982.
Revised: 0068T, 0069T, 0070T, and 0087T.
Deleted: 0153T, and 0154T.

07/01/08

HCPCS Update: code 0124T descriptor updated.
Deleted codes 0171T, and 0172T as they are now listed in the new MCG: 02-20000-36 – Interspinous Process Distraction Devices (Spacers).
Also removed codes 61630, 61635, 61640, 61641, and 61642 as they are now listed in the new MCG: 02-61000-35 – Percutaneous Transluminal Intracranial Angioplasty and Stenting.

10/22/08

Deleted code 0073T.

01/01/09

Annual HCPCS coding update: added codes 0194T, 0197T, 0198T, 65756, 65757, 95803, & S2117; updated descriptor for codes 0184T & 34806; deleted codes 0041T, 0043T, 0061T, 0089T, and 0137T.

04/01/09

2nd quarter HCPCS update: added codes S3865, S3866, S3870.

05/15/09

2nd quarter HCPCS update: deleted code 0184T; updated descriptor for 0182T.

07/01/09

3rd quarter HCPCS update. Consisting of add code 0202T.

11/15/09

4th quarter HCPCS update. Consisting of deleting code 0202T.

12/15/09

Added position statement regarding complementary or alternative medicine diagnostic testing.

01/01/10

Annual HCPCS coding update: added codes 0205T, 0208T, 0209T, 0210T, 0211T, 0212T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 46707, 84145, 86352, and G9143; deleted codes 0068T, 0069T, 0070T, 0077T, 0086T, 0087T, 0170T, and 0194T.

01/27/10

Added code 0190T.

02/15/10

Deleted code 0197T.

03/15/10

Removed codes G9143, 0195T, and 0196T.

04/15/10

Deleted CPT codes 0182T, 65756, and 65757.

05/15/10

Deleted CPT code 92065.

07/01/10

3rd quarter HCPCS coding update: added codes 0223T, 0224T, 0225T, 0226T, 0227T, 0228T, 0229T, 0230T, 0231T and 0233T.

12/15/10

Revision: deleted codes S3865, S3866 and S3870 (the codes were added to the Genetic Testing guideline).

01/01/11

Annual HCPCS coding update. Added 0240T, 0241T, 66174, and 66175; deleted 0104T, 0105T, 0176T, 0177T, 0187T.

01/15/11

Deleted codes 0223T, 0224T, 0225T, and 46707 (codes included in other active guidelines).

07/01/11

3rd quarter HCPCS coding update. Added 0262T – 0275T.

01/01/12

Annual HCPCS coding update. Added codes 0278T-0301T; revised codes 0240T, 0241T, and deleted codes 0166T-0168T.

02/20/12

Updated description section.

04/01/12

Quarterly HCPCS update. Added code S3721.

05/15/12

Deleted codes 0226T and 0227T (new MCG developed for these services).

05/23/12

Deleted code 0042T.

07/01/12

Quarterly HCPCS update. Added codes 0302T-0308T.

09/15/12

Removed code S2117 (new MCG developed) and codes 0228T-0231T (added to the Epidural Injections MCG).

10/15/12

Removed code S3721 (added to the Genetic Testing guideline); removed code 0301T (included in the Microwave Thermotherapy for Breast Cancer MCG).

01/01/13

Annual HCPCS update. Added codes G0455, 44075, 0319T-0328T; deleted code 0030T.

02/15/13

Revision, codes 0181T, 0262T-0265T, 0274T, 0275T, 0302T-0307T updated (* removed).

05/15/13

Added code S8930.

07/01/13

Quarterly HCPCS update. Added codes 0329T, 0330T, 0331T, 0332T and 0334T.

10/15/13

Revision; codes 0213T, 0214T, 0215T, 0216T, 0217T and 0218T deleted (added to 02-61000-30, Facet Joint Injections).

01/01/14

Annual HCPCS update. Added codes A4555, E0766, 97610, 0336T, 0337T, 0338T, 0339T, 0343T-0346T; deleted codes 0124T, 0183T, 0186T. Description and program exception sections updated (all * removed)

03/15/14

Revision; deleted code 0334T (added to Minimally Invasive Fusion Techniques)

07/01/14

Quarterly HCPCS update. Added codes 0347T-0356T.

07/15/14

Removed codes 66174 and 66175 (added to Viscocanalostomy and Canaloplasty MCG)

08/15/14

Revision; deleted codes 44705 and G0455 (added to 02-40000-24, Fecal Microbiota Transplantation)

11/15/14

Removed code 0336T (added to Laparoscopic and Percutaneous Techniques for the Treatment of Uterine MCG).

01/01/15

Annual CPT/HCPCS update. Added codes 33418, 33419, 91200, 92145, 93895, 0377T, & 0381T-0391T; deleted codes 0181T, 0343T, 0344T.

02/18/15

Deleted code 91200 [Fibroscan].

04/15/15

Deleted code 0262T.

05/20/15

Deleted codes 0274T, 0275T, & 0377T; codes included in other guidelines.

11/01/15

Revision: ICD-9 Code references deleted.

12/15/15

Revision; added codes 33265, 33266.

01/01/16

Annual CPT/HCPCS update. Added codes 43210; 0396T; 0398T, 0402T-0418T,0421T, 0422T and 0423T-0436T; revised code 0308T; deleted codes 0123T, 0233T, 0240T, 0241T.

01/15/16

Deleted codes A4555 and E0766 (added to Tumor Treatment Fields Therapy for Glioblastoma).

04/15/16

Deleted code 0281T (added to Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation).

06/15/16

Deleted code 43210. (See MCG 01-91000-03, Minimally Invasive Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) and Dysphagia).

07/01/16

Quarterly CPT/HCPCS update. Added codes 0443T, 0444T and 0445T.

09/15/16

Deleted codes 33418, 33419, & 0345T (see policy 02-33000-35, Transcatheter Mitral Valve Repair (TMVR))

11/15/16

Added code S2103, 91132, 91133 and S9001.

12/15/16

Deleted code 95803; added to policy 01-95828-01 Sleep Testing.

01/01/17

Annual CPT/HCPCS update. Added 0466T-0468T; deleted 0169T, 0281T-0286T, 0291T, 0292T.

04/15/17

Revision; Codes 43252, 82610, 83880, 85384, 85385 added.

07/01/17

Quarterly CPT/HCPCS update. Added codes 0470T and 0471T.

07/15/17

Revision; code 83880 removed.

08/01/17

Coding update: Added codes 0006U & 0011U.

Date Printed: August 22, 2017: 07:06 AM