January, February, and March 2010 Policy Updates

New Policies

March 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Endoscopic Treatment of GERD L30473 GI-010 04/15/2010
Epidural and Transforaminal Epidural Injections L30481 NEURO-007 04/15/2010

February 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Corneal Pachymetry L30485 OPHTH-025 03/18/2010
    This LCD becomes final 03/18/2010 for all WPS Medicare contracts and replaces
    all other WPS Medicare policies on this topic.
Cytogenetic Studies L30487 PATH-027 03/18/2010
Health and Behavior Assessment/Intervention L30514 PSYCH-015 03/18/2010
Luteinizing Hormone-Releasing Hormone (LHRH)
Analogs		 L30479 INJ-039 03/18/2010
Paravertebral Facet Joint Block and Facet
Joint Denervation		 L30483 NEURO-008 03/18/2010
Psychiatry and Psychology Services L30489 PSYCH-014 03/18/2010
LCD L30489 becomes final 03/18/2010 for all WPS Medicare contracts and replaces all other WPS Medicare policies on this topic.

January 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Allergy Testing and Allergy Immunotherapy DL30471 ALRG-001 02/16/2010
This policy will be in effect across all WPS jurisdictions.
Electromagnetic Navigation Bronchoscopy (ENB) L30510 PULM-007 02/15/2010

Retired Policies

March 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Allergy Immunotherapy L26618 ALRG-501 02/16/2010
Allergy Testing L26620 ALRG-502 02/16/2010
The policies listed above were replaced with policy Allergy Testing and Allergy Immunotherapy L30471 on 02/16/2010
Endoscopic Treatment of GERD L26646 GI-510 04/14/2010
Injection of Spinal Canal L26711 NEURO-507 04/14/2010
This LCD is being retired and replaced with L30481

February 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Cytogenetic Studies L26684 PATH-527 03/18/2010
Gonadotropin-Releasing Hormone Analogs L26657 INJ-539 03/17/2010
This LCD for MAC Part B is retired and replaced by L30479 entitled Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Pachymetry L26677 OPHTH-025 03/18/2010
This WPS Medicare MAC Part B LCD is retired effective 03/17/2010 and replaced by LCD L30485 entitled Corneal Pachymetry.
Paravertebral Facet Joint Block and Facet Denervation L26665 NEURO-508 03/17/2010
This LCD is being replaced by L30483
Psychological and Neuropsychological Incident to L26690 PSYCH-513 03/18/2010
Psychiatric Pharmacotherapy L26691 PSYCH-516 03/18/2010

January 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Low Vision Services L26679 OPHTH-526 01/01/2010
The policy entitled Low Vision Services is retired January 1, 2010. There is no replacement LCD.
Non-Invasive Pulse Oximetry for Oxygen Saturation L26692 PULM-501 02/01/2010
Policy being retired and is not replaced by a new policy. Policy retired after review of utilization data. Retire effective date 02/01/2010.

Revised Policies

March 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Ablative Therapy L30312 GSURG-033 03/01/2010
CPT/HCPCS Codes
Group II
The following codes, when used as described below, are covered services.

*47382 Ablation, one or more liver tumor(s); percutaneous, radiofrequency
Bone Mass Measurement Coding and Billing Guidelines L28527 MS-004 03/01/2010
In the companion Coding and Billing Guidelines for LCD Bone Mass Measurement, added to the list of osteoporosis drug therapies, zolodronic acid (Reclast). This list is not intended as all-inclusive. Reclast is effective for DOS 08/17/2007 and after
Computerized Tomography (CAT Scans) L28544 RAD-033 03/01/2010
03/01/2010, Addition of ICD-9 code 959.01 to cervical spine section (72125-72127) effective 01/01/2010
Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA) NA NA NA
The EPO/DPA Part B Worksheet has been removed from the coding guidelines. The information can be found in the body of the policy.
Flow Cytometry L30161 PATH-016 11/16/2009
ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
A. CPT codes 88184-88189 are indicated for the following conditions:

1. HIV infection (ICD-9 042, 079.51, 079.52, 079.53, *V0.8), as defined by the Center for Disease Control criteria.
2. Leukemias (ICD-9 204.00-208.92)
3. Lymphomas (ICD-9 200.00-203.82)
4. Abnormal tissue, bone marrow, or blood histology when the results are suspicious for lymphoma, leukemia or MDS and where the physician must distinguish reactive from neoplastic conditions (ICD-9 238.6, 238.71- 238.79, 285.9, *287.30- 287.5, 795.4).
5. Platelet defects (ICD-9 287.1)
6. Postoperative monitoring of organ transplant patients (ICD-9 996.80-996.89, V42.0-V42.89).
7. Pretransplant evaluation of allogenic or autologous donor cells (V42.82)
8. Primary immunodeficiencies (ICD-9 279.10-279.9, 288.09, 334.8)
9. Monoclonal gammopathies (ICD-9 273.1, 273.3)
*10. Certain anemias
Acquired hemolytic anemia, unspecified *283.9
Constitutional aplastic anemia *284.0
Constitutional red cell aplasia *284.01
Other constitutional aplastic anemia *284.09
Pancytopenia -myelopthisis *284.1 - 284.2
Other specified aplastic anemia *284.89
Aplastic anemia, unspecified *284.9
Sideroblastic anemia *285.0
Anemia in neoplastic disease *285.22
Other anemia *285.8 - 285.9
*11. Diseases of white blood cells
Neutropenia, unspecified - neutropenia due to Infection *288.00 - 288.04
Other neutropenia 288.09
Functional disorders of polymorphonuclear Neutrophils - hemophagocytic syndromes *288.1 - 288.4
Leukocytopenia, unspecified - lymphocytopenia *288.50 - 288.51
Other decreased white blood cell count *288.59
Leukocytosis, unspecified - basophilia *288.60 - 288.65
Other elevated white blood cell count *288.69
Other specified diseases of white blood cells *288.8 - 288.9
12. Certain hemolytic anemias:
Paroxysmal nocturnal hemoglobinuria (ICD-9 283.2)
Portal vein thrombosis *452
Embolism of vein thrombosis, unspecified *453.9
Hereditary spherocytosis (ICD-9 282.0)
Sickle cell (ICD-9 282.5, 282.60-282.69)
HPFH (ICD-9 282.7)
13. Drug monitoring (ICD-9 V58.69)
14. Conditions associated with gene HLA B27
Reiter's syndrome (ICD-9 099.3)
Uveitis (ICD-9 364.3)
Psoriatic arthritis (ICD-9 696.0)
Juvenile arthritis (ICD-9 714.30)
Ankylosing spondylitis (ICD-9 720.0-720.9)
Inflammatory bowel disease (ICD-9 555.0-556.9)
15. Splenomegaly (ICD-9 789.2)
16. Abdominal mass (ICD-9 789.30- 789.39)
Immune Globulins L30147 INJ-012 03/01/2010
The following updates have been made to this LCD: 30. Stiff-man syndrome (333.91) IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. Documentation must support objective response for continued coverage each month or at longer intervals"

Documentation Requirements
Documentation must support objective response for continued coverage.
Noninvasive Vascular Testing (N.I.V.T.) L28586 CV-033 05/01/2010
A. Training and Certification
*5. Transcutaneous Oxygen measurement (93922-93923) may be performed by personnel possessing the following credentials obtained from the National Board of Diving and Hyperbaric Medicine Technology (NBDHMT):
   a. Certified Hyperbaric Technologist (CHT)
   b. Certified Hyperbaric Registered Nurse (CHRN)
Outpatient Rehabilitation Therapy Services billed to Medicare Part B L28531 PHYSMED-009 01/01/2010
As of December 31, 2009, the outpatient therapy caps exception process expired and the therapy caps went into effect without exceptions. Outpatient hospital services are not subject to therapy caps. Effective for dates of service on and after January 1, 2010, there will be no exceptions process in place and therapy providers should not submit therapy claims with KX modifiers.
Procedure Codes Payable for Podiatrist NA NA NA
The following procedure codes have been added to the list of HCPCS codes approved as payable for podiatrists by the medical director staff.

Policy Name & Number     Added Codes
Podiatry Code List      28039, 29581, 99304, 99305

February 2010

Policy Title MCD Policy # WPS Policy # Effective Date
Bisphosphonate Drug Therapy L30139 INJ-025 *10/16/2009
ICD-9 Codes that Support Medical Necessity

J3487 Zolendronic acid (Zoledronate) (Zometa), 198.5, 203.00, 203.01, 203.02, 275.42, *728.10-728.12, 731.0, 733.00 -733.09, *958.6
J2430 Pamidronate only 198.5, 203.00, 203.01, 203.02, 275.42, 731.0, , *728.10-728.12, 733-00 -733.09, 756.51, 756.54, 756.59, *958.6

The above marked ICD-9 codes were inadvertently left off the list of covered codes and are now being replaced.
Botulinum Toxin Type A & Type B L28555 INJ-018 02/01/2010
02/01/2010, added CPT code 53899, added ICD-9 596.59 and 788.41 with an effective date of 05/16/2009;
Chemotherapy Drugs and their Adjuncts L28576 HONC-010 02/01/2010
The following updates have been made to this LCD:
2.  Trastuzumab (Herceptin) 10 mg (J9355)
Esophageal -when used in combination with systemic chemotherapy for the treatment of patients with advanced esophageal or gastroesophageal junction adenocarcinoma that is HER-2-positive by a standardized method 150.0-150.9

33.  Octreotide, Depot Form for Intramuscular Injection, 1 mg.(Sandostatin LAR Depot) (J2353)
Neuroendocrine tumors 209.00-209.03, 209.10-209.17, 209.20-209.29, 209.30, 209.70

40.  Pemetrexed Disodium (Alimta ), 10 mg (J9305)
Bladder cancer-as second-line therapy as a single agent for metastatic disease 188.0-188.9, 233.7
Intra-articular Injections of Hyaluronan Billing and Coding Guidelines L30149 INJ-033 01/01/2010
J7325 was removed from instruction #1 and #2 was added to the document.
  1. HCPCS code J7321, J7323, and J7324 are per dose codes. When the injections are administered bilaterally, list J7321, J7323 or J7324 in item 24 (FAO-09 electronically) with a 2 in the unit's field.


    2. J7321 Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose
    J7323 Hyaluronan or Derivative, Euflexxa, For Intra-Articular Injection, Per Dose
    J7324 Hyaluronan or Derivative, Orthovisc, For Intra-Articular Injection, Per Dose

  2. HCPC's J7325 is defined by milligrams.
    3. J7325 Hyaluronan or Derivative, Synvisc or Synvisc-One, For Intra-Articular Injection, 1mg

    When this injection is administered either unilaterally or bilaterally the injections would be billed by placing J7325 in item 24 (FAO-09 electronically) and listing the total number of mg's administered in the units field.

    There are 2 different products that are billed using this code.

    Synvisc® - (16mg/2ml) - injection is given once a week (i.e., at seven-day intervals) for a total of three injections.

    Synvisc-OneTM- (48mg/6ml) - single dose injection

January 2010

Policy Title MCD Policy # WPS Policy # Effective Date
2010 CPT/HCPCS Code Update Various Various New Codes: 01/01/2010
Deleted Codes: 12/31/2009
Please see the 2010 CPT/HCPCS Code Update article for details about the updates
CT Colonography (Virtual Colonoscopy [VC]) L30300 RAD-035 01/01/2010
Revision to the Documentation Requirements:
3. Medical records must be available to document a conventional colonoscopy has failed or documentation supporting the contraindication to an optical colonoscopy. These records must be available upon request.

Removed "within 30 days" requirement."
Chemotherapy Drugs and their Adjuncts L28576 HONC-010 01/01/2010
The following updates have been made to this LCD:
9. Bortezomib (VelcadeTM) (J9041), 0.1mg
Waldenstrom's Macroglobulinemia (273.3)

18. Doxorubicin Hydrochloride, all lipid formulations, 10 mg (Doxil) (J9001)
Hodgkin disease-Second line treatment prior to autologous stem cell rescue in patients initially treated with chemotherapy alone or in combination with radiation therapy. (201.50-201.58, 201.60-201.68, 201.70-201.78, 201.90-201.98)

22. Gemcitabine Hydrochloride (Gemzar) 200 mg (J9201)
Carcinoma of unknown primary Chemoradiation in combination with cisplatin or docetaxel in symptomatic patients with performance status 1-2 or asymptomatic patients with aggressive disease for localized disease with inguinal nodal involvement. (199.0, 199.1)

35. Paclitaxel (Taxol) 30mg (J9265)
Angiosarcoma 171.0, 171.3, 171.5, 171.9

47. Vinorelbine tartrate (Navelbine) per 10 mg (J9390)
Hodgkin disease-Second line treatment prior to autologous stem cell rescue in patients initially treated with chemotherapy alone or in combination with radiation therapy as a component of one of the following regimens: GVD or IGEV. (201.50-201.58, 201.60-201.68, 201.70-201.78, 201.90-201.98)

Correction: The effective date of ICD-9 code 190.9 for J9015 has been changed to 05/16/09
Computed Coronary Tomography Angiography L30288 RAD-034 01/01/2010
LCD Revisions: Effective 01/01/2010, CPT/HCPCS 2010 coding update; Removed specific CPT code designation requirement for a specific ICD-9 code designation, effective 08/16/2009.

Coding and Billing Guidelines Revisions: 01/01/2010: Under section entitled Reasons for Denial, " sentence number four, deleted codes 0144T, 10150T and 0151T per 2010 CPT Coding updates and replaced with new 2010 CPT codes 75571 and 75573. Under section entitled "Coding and Billing Guidelines" added sentence number four.
Helicobacter Pylori L30163 PATH-026 01/01/2010
Policy revision based on LCD reconsideration request, narrative revision to "Indications and Limitations" section of policy, revision does not change coverage or claims processing, effective date of narrative change is 02/01/2009. Added revenue code 031X for CPT codes 78267-78268 with effective date for claims processing of 09/16/2009.
Intra-articular Injections of Hyaluronan L30149 INJ-033 01/01/2010
The following information has been added to the LCD:

Utilization Guidelines
Repeat treatments are considered medically necessary for patients being treated for osteoarthritis of the knee, who meet both of the following criteria:
  • Significant improvement in knee pain and known improvement in functional capacity resulted from the previous series of injections which has been documented in the record; and
  • At least six (6) months have elapsed since the prior series of injections.
Documentation Requirements
If subsequent courses of treatment are given, the medical records must support the effectiveness of the prior treatment and must clearly establish reduction of patient symptomatology and medication usage. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medically necessary.
Routine Foot Care L30322 FT-001 01/01/2010
*01/01/2009, Removed statement, per MBPM, Chapter 15, 290 - "or qualified non-physician practitioner", 12/01/2009, Removed all information except that which is directly related to routine foot care, added third list of ICD-9 codes where the patient has evidence of neuropathy, but no vascular impairment for which class finding modifiers are not required, added "Note: Painful ingrown toenail" in reference to ICD-9 code 703.0.
Vitamin B-12 Injections L30145 INJ-004 01/01/2010
Revision to ICD-9 coding. Added codes V07.39 and V58.69 deleted V67.51. Revision based on correction of coding for prophylactic B-12 injection use for certain chemotherapy drugs that are B-12 deleting medications. Revision effective date 02/01/2010.

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Page Last Updated: Wednesday, 14-Dec-2011 10:22:44 CST