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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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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 | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 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. |
87475 | Lyme dis dna dir probe | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY 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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
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. |
J0550 | Penicillin g benzathine inj | HCPCS | 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 | 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 | 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. |
J0580 | Penicillin g benzathine inj | HCPCS | 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. |
J0560 | Penicillin g benzathine inj | HCPCS | 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. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 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. |
J0580 | Penicillin g benzathine inj | HCPCS | 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. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0560 | Penicillin g benzathine inj | HCPCS | 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. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 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. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 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. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. |
J0580 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0560 | Penicillin g benzathine inj | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. |
J0580 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0560 | Penicillin g benzathine inj | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0570 | Buprenorphine implant, 74.2 mg | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
J0561 | PR PENICILLIN G BENZATHINE INJ 100,000 UNITS | HCPCS | Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal. |
V5363 | Language screening | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5336 | Repair communication device | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92507 | Treatment of speech, language, voice, communication, and/or hearing processing disorder | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5273 | Ald for cochlear implant | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92508 | Speech/hearing therapy | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5269 | Alerting device, any type | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92510 | Rehab for ear implant | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
L8615 | Headset/headpiece for use with cochlear implant device, replacement | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
L8617 | Transmitting coil for use with cochlear implant device, replacement | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92601 | PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5299 | Hearing service | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5362 | Speech screening | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92604 | Reprogram cochlear implt 7/> | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
L8618 | Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
1999 | ANESTHESIOLOGY GROUP | CPT | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92603 | PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
L8619 | PROCESSOR SOUND SONNET/RONDO 3 KT | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
92602 | Reprogram cochlear implt <7 | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
69949 | Unlisted px inner ear | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
L8616 | Microphone for use with cochlear implant device, replacement | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. |
V5363 | Language screening | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5336 | Repair communication device | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92507 | Treatment of speech, language, voice, communication, and/or hearing processing disorder | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5273 | Ald for cochlear implant | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92508 | Speech/hearing therapy | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5269 | Alerting device, any type | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92510 | Rehab for ear implant | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
L8615 | Headset/headpiece for use with cochlear implant device, replacement | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
L8617 | Transmitting coil for use with cochlear implant device, replacement | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92601 | PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5299 | Hearing service | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5362 | Speech screening | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92604 | Reprogram cochlear implt 7/> | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
L8618 | Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92603 | PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
L8619 | PROCESSOR SOUND SONNET/RONDO 3 KT | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
92602 | Reprogram cochlear implt <7 | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
69949 | Unlisted px inner ear | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
L8616 | Microphone for use with cochlear implant device, replacement | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. |
V5363 | Language screening | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
V5336 | Repair communication device | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92507 | Treatment of speech, language, voice, communication, and/or hearing processing disorder | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
V5273 | Ald for cochlear implant | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92508 | Speech/hearing therapy | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
V5269 | Alerting device, any type | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92510 | Rehab for ear implant | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8615 | Headset/headpiece for use with cochlear implant device, replacement | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8617 | Transmitting coil for use with cochlear implant device, replacement | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92601 | PR ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
V5299 | Hearing service | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
V5362 | Speech screening | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92604 | Reprogram cochlear implt 7/> | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8618 | Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92603 | PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8619 | PROCESSOR SOUND SONNET/RONDO 3 KT | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
92602 | Reprogram cochlear implt <7 | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
69949 | Unlisted px inner ear | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8616 | Microphone for use with cochlear implant device, replacement | HCPCS | POLICY HISTORY7/1992: Approved by Medical Policy Advisory Committee (MPAC)
12/30/1999: Policy Guidelines updated
9/21/2001:Policy rewritten to be reflective of Blue Cross Blue Shield Association policy # 7.01.05, Code Reference section updated, CPT code 92507, 92510 added
11/2001: Reviewed by MPAC; revisions approved
4/18/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, CPT code 69949 added, HCPCS L8619, V5269, V5273, V5299, V5336, V5362, V5363 added
3/6/2003: Code Reference section updated, CPT code 92601, 92602, 92603, 92604 added
7/15/2004: Reviewed by MPAC, bilateral cochlear implantation considered investigational, Description section aligned with BCBSA policy # 7.01.05, definition of investigational added Policy Guidelines, Sources updated
10/5/2004: Code Reference section updated, CPT code 69949 deleted, CPT 92507 description revised, CPT 92508 added, ICD-9 procedure code 20.96, 20.97, 20.99, 95.49 added, ICD-9 diagnosis code range 389.10-389.18 listed separately, ICD-9 diagnosis 389.7 added, HCPCS L8619 note added, HCPCS V5269, V5273, V5299, V5336, V5362, V5363 deleted
3/22/2005: Code Reference section updated, CPT code 92510 description revised, HCPCS L8615, L8616, L8617, L8618 with Note: "See POLICY GUIDELINES for information regarding replacement of the external component of the cochlear implant" and effective date of 1/1/2005 added. 11/15/2005: HCPCS codes K0731, K0732, L8620 added
03/10/2006: Coding updated. CPT4 / HCPCS 2006 revisions added to policy
03/13/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. |
L8627 | Cochlear implant, external speech processor, component, replacement | HCPCS | ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. |
L8628 | Cochlear implant, external controller component, replacement | HCPCS | ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. |
L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | HCPCS | ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 HCPCS revisions
3/27/2007: Policy reviewed, no changes to policy statement. Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. |
L8627 | Cochlear implant, external speech processor, component, replacement | HCPCS | Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. |
L8628 | Cochlear implant, external controller component, replacement | HCPCS | Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. |
L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | HCPCS | Bilateral cochlear implantation added to Policy Guidelines section
06/26/2007: Policy statement updated; bilateral cochlear implantation changed from investigational to may be considered medically necessary
7/19/2007: Reviewed and approved by MPAC
9/18/2007: Code reference section updated. ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. |
L8627 | Cochlear implant, external speech processor, component, replacement | HCPCS | ICD-9 2007 revisions added to policy
1/7/2009: Policy reviewed, policy section partially rewritten and clarified. 3/12/2010: Code Reference section updated. New HCPCS codes L8627, L8628 and L8629 added to covered table. 04/26/2010: Policy description updated regarding devices. Policy statements modified for clarity; intent unchanged. |
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