Radiopharmaceutical Agents (L31361)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
L31361 LCD Title Radiopharmaceutical Agents Contractor's Determination Number RAD-026 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 07/16/2011 Original Determination Ending Date Revision Effective Date For services performed on or after 05/01/2012 Revision Ending Date |
CMS PUB 100-03, §1 Part 4, Section 220.6
CMS PUB 100-02 One time Notification -Change Request 3007
The following radiopharmaceuticals will be considered medically necessary when used with the procedures listed below.
mCi = millicurie
A. Technetium (Tc) labeled radiopharmaceuticals:
1. Technetium Tc-99m Arcitumomab (CEA scan), Diagnostic, per study dose, up to 45 mCi's A9568
Immunoscintigraphy, using single-photon emission computed tomography (SPECT) (CPT 78800-78804)
2. Technetium Tc-99m Bicisate (Neurolite®), Diagnostic, per study dose, up to 25 mCi's A9557
Brain imaging (CPT 78600-78607, 78610)
3. Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 mCi's, A9551
Parenchymal renal scan. (CPT-4 Codes 78700-78710)
Tumor detection (CPT 78800-78804)
4. Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mCi's, A9539
Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)
Testicular imaging with vascular flow (CPT 78761)
GFR renal scan. (CPT 78700-78725)
Urinary bladder residual (CPT 78730)
Ureteral reflux (CPT 78740)
CSF study. (CPT 78630-78650)
Brain study. (CPT 78600-78607, 78610)
Shunt patency agent. 500 uCi (CPT 78291, 78645)
First-pass cardiac technique studies (CPT 78481, 78483)
Vascular flow study (CPT 78445)
Cardiac Shunt detection (78428)
5. Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mCi's, A9567
Lung ventilation (CPT 78579, 78580, 78582, 78597, 78598)
6. Technetium Tc-99m Disofenin (Hepatolite, DISIDA) A9510, per study dose, up to 15 mCi's
Hepatobiliary scan agent. (CPT 78226, 78227)
7. Technetium Tc-99m Exametazine (Ceretec®), Diagnostic, per study dose, up to 25 mCi's, A9521
Brain perfusion. (CPT 78600-78607, 78610)
8. Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose, A9569
Infection detection (CPT 78805-78807)
9. TechnetiumTc-99m Human Serum Albumin A4641
Usual Dosage 2-20 mCi
CSF Leak Study (CPT 78630-78652)
Blood pool agent (CPT 78414-78458)
Lymphatic imaging (CPT 78195)
10. Technetium Tc-99m Iminodiacetic Acid (IDA) A4641
Usual Dosage 5-12 mCi
Hepatobiliary scan agent. (CPT 78226, 78227)
11. Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi's, A9540
Lung perfusion agent (CPT 78580, 78582, 78597, 78598)
Peritoneal-Venous Shunt Study (CPT 78291)
Peritoneal cavity imaging prior to intraperitoneal chemotherapy (78800, 78801, 78803)
Cardiac Shunt Detection (CPT 78216, 78428)
Liver imaging (SPECT) (CPT 78201, 78205, 78215)
12. Technetium Tc-99m Mebrofenin (Choletec) Diagnostic, per study dose, up to 15 mCi's A9537
Hepatobiliary scan agent. (CPT 78226, 78227)
13. Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 15 mCi's A9562
Renal scan agent (CPT 78700-78725)
14. Technetium Tc 99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mCi's (A9503)
Bone scan (CPT 78300-78320, 78399)
15. Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 mCi's. A9561
Bone scan agent (CPT 78300-78320, 78399)
16. Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi, A9512
Thyroid study (CPT 78000-78001, 78006-78007, 78010, 78011, 78015)
Brain death (CPT 78600-78607, 78610)
First-pass cardiac technique studies (CPT 78481, 78483)
Meckel's diverticulum 10-20 mCi (CPT-4 Codes 78261, 78290)
Parathyroid study (CPT 78070)
Parotid or salivary scan (CPT 78230-78232)
Gastric mucosa (CPT 78261, 78290)
Urinary bladder residual (CPT 78730)
Ureteral reflux study (CPT 78740)
Dacryocystography (CPT 78660)
Testicular imaging with vascular flow (CPT 78761)
Peritoneal-Venous Shunt Study (CPT 78291)
Cerebrospinal Fluid study (CPT 78630-78650)
17. Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite®) Diagnostic, per study dose, up to 25 mCi's A9538
Bone (CPT 78300-78320)
Amyloid imaging (CPT 78999)
Myocardial Infarct imaging (78466-78469)
18. Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mCi's, A9560 (Ultra Tag ® or cold pyrophosphate (pyp) +99m technetium),
Cardiac blood pool imaging / Gated Equilibrium studies (78472, 78473, 78494, 78496)
GI bleed study (CPT 78278)
Liver scan (for Hemangioma) (CPT 78201-78206)
Vascular flow study (CPT 78445)
Venous thrombosis imaging (CPT 78457-78458)
Spleen imaging (CPT 78215, 78216, 78185)
19. Technetium Tc-99m, Sestamibi, diagnostic, per study dose, A9500
Cardiac perfusion (CPT 78451-78454)
Parathyroid study (CPT 78070)
Tumor (CPT 78605-78607, 78800-78804)
Breast tumor (CPT 78800, 78801)
20. Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to 20 mCi's A9541
Liver spleen scans. (CPT 78201-78216)
Spleen scan (CPT 78185)
GI bleed studies (CPT 78278)
Bone marrow studies (CPT 78102-78104)
Gastric emptying, gastric emptying with colonic transit studies (CPT 78264, 78299)
Gastroesophageal reflux studies (CPT 78258, 78262)
Ureteral reflux study (CPT 78740)
Urinary bladder residual study (CPT 78730)
Lymphatics & Lymph glands (CPT 78195)
Peritoneal-pleural shunt studies (CPT 78291)
21. Technetium Tc 99m tetrofosmin, diagnostic, per study dose, A9502 (Myoview)
Myocardial perfusion studies (CPT 78451-78454)
Parathyroid study (CPT 78070, 78803)
B. Iodine labeled radiopharmaceuticals:
1. I 123
a. Hippurate (Orthoiodohippurate) A4641
Usual Dosage 150-250 uCi
Renogram. (CPT 78700-78725)
b. Iodine I-123 Sodium iodide capsule(s), Diagnostic A9516 per 100 Microcuries, up to 999 microcuries
Thyroid imaging (CPT 78000-78018, 78020, 78070)
c. Iodine I-123 Sodium Iodide, diagnostic, per millicurie (A9509)
Thyroid imaging (CPT 78000-78018, 78020, 78070)
d. Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries A9582 (AdreView®)
Adrenal imaging/ Pheochromocytoma (CPT 78075)
neuroblastoma imaging. (78800-78804)
e. Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (DaTscan„¢-FDA approved 01/14/2011) (A9584).
78607 Brain Imaging, tomographic (SPECT)
2. I 125
a. Iodine-125 sodium iothalamate (Glofil-125®), Diagnostic, per study dose, up to 10 microcuries, A9554
Renogram (CPT 78707-78709, 78725)
b. Iodinated I-125-Serum Albumin, Diagnostic, per 5 microcuries, A9532
Plasma Volume (CPT 78110-78111, 78122)
c. Iodine- 125 Sodium Iodide solution, Therapeutic, per millicurie A9527
Hyperthyroidism or thyroid cancer (CPT 79005)
Intracavitary radiation source application, simple (77761)
3. I 131
a. Hippurate (Orthoiodohippurate) A4641
Usual Dosage 150-250 uCi
Renogram (CPT 78707-78709, 78725)
b. Iobenguane sulfate-Metaiodobenzyl guanidine (MIBG) per 0.5 mCi, A9508
Adrenal imaging/ Pheochromocytoma (CPT 78075)
Neuroblastoma imaging. (78800-78804)
c. Iodine I-131 Sodium Iodide capsule(s), Therapeutic, per mCi, A9517
Hyperthyroidism or thyroid cancer (CPT 79005)
d. Iodine I-131 Sodium Iodide solution, Therapeutic, per mCi, A9530
Hyperthyroidism or thyroid cancer (CPT 79005)
e. Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mCi, A9528
Thyroid uptake and imaging (CPT 78000-78020, 78803)
f. Iodine I-131 Sodium Iodide solution, Diagnostic, per mCi, A9529
Thyroid uptake and imaging (CPT 78000-78020, 78803)
g. Iodine I-131 Sodium Iodide, Diagnostic, per microcurie (up to 100 microcuries) A9531
Thyroid uptake and imaging (CPT 78000-78020, 78803)
4. Iodine I-131 Tositumomab, (Bexxar®) Diagnostic, per study dose, A9544
Tumor imaging (CPT 78804)
5. Iodine I-131 Tositumomab, (Bexxar®) Therapeutic, per treatment dose, A9545
Radiopharmaceutical therapy, radiolabeled monoclonal antibody by IV infusion (CPT 79403)
6. Iodinated I-131-Serum Albumin, diagnostic, per 5 microcuries, A9524
Plasma Volume (CPT 78110-78111, 78122)
Brain imaging (CPT 78600-78607, 78610)
Pulmonary perfusion imaging (CPT 78580, 78582, 78597, 78598)
Cardiac imaging (CPT 78451-78454)
Tumor imaging (CPT 78800-78804)
Cardiac Blood Pooling imaging (CPT 78472-78473, 78481-78483)
C. Indium labeled Radiopharmaceuticals:
1. Indium IN 111 Capromab Pendetide (ProstaScint®) per study dose, up to 10 mci's (A9507)
Tumor detection (CPT 78800-78804)
2. Indium -111 Diethylenetriamine Pentaacetic acid (DTPA) A4641
Usual Dosage 500 uCi
Cisternography or CSF leak detection, or shunt patency evaluation (CPT 78630-78650)
Gastric emptying (CPT 78264)
3. Indium IN-111 Pentetate Diagnostic, per 0.5 mCi A9548 (MPI INDIUM DTPA IN 111)
Cisternogram (cerebrospinal fluid flow) (CPT 78630)
Cerebrospinal ventriculography (CPT 78635)
CSF Shunt evaluation (CPT 78645)
Cerebrospinal fluid scan (CPT 78647)
CSF Leakage detection and localization (CPT 78650)
Localization of tumor or distribution of radiopharmaceutical agent (78800)
4. Indium-IN-111 Oxyquinoline, Diagnostic, per 0.5 mCi, A9547
Leukocyte labeling (CPT 78805-78807, 78185)
Platelet labeling. (CPT 78190-78191, 78199)
5. Indium-111 Pentetreotide (OctreoScan®), Diagnostic, per study dose, up to 6 millicuries (A9572)
Agent for localization of primary and metastatic neuroendocrine tumors bearing somatostatic receptors (CPT 78075, 78800-78804, 78015-78018)
6. Indium-111 Satumomab pendetide, diagnostic, per study dose, up to 6 mci's (OncoScint®) A4642
Agent for imaging colorectal or ovarian cancers (CPT 78800-78804)
7. Indium-IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to 5 mCi's A9542 (Zevalin®) and Yttrium-90 Ibritumomab Tiuxetan, Therapeutic, per treatment dose, up to 40 mCi's A9543 (Zevalin®)
a. To report the procedure for determining the biodistribution of Zevalin use procedure code 78804 and the diagnostic imaging agent, A9542- Indium IN-111-Ibritumomab Tiuxetan.
78804 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent (s); whole body, requiring 2 or more days imaging.
This procedure encompasses administration of indium labeled Zevalin followed by whole body radionuclide scanning 2-24 hours and 48-72 hours after the administration of Zevalin. This code may only be reported once, no matter how many scans are performed.
b. To report the radiopharmaceutical therapy using radiolabeled monoclonal antibodies for the treatment of non-Hodgkin's lymphoma use code 79403 and the therapeutic imaging agent, A9543-Yttrium 90 Ibritumomab Tiuxetan.
79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion.
This code includes the physician service, which includes counseling the patient and family, setting up and infusing the radiopharmaceutical and post-procedure time reviewing the appropriate blood work.
8. Indium-111 Hydrochloride (HCL) A4641
Usual dosage 0.1-1.0 mCi
Gastric emptying with colonic transit study (CPT 78299)
9. Indium-111 labeled autologous white blood cells, diagnostic, per study dose (A9570)
Leukocyte labeling (CPT 78805-78807, 78185)
10. Indium in-111 labeled autologous platelets, diagnostic, per study dose (A9571)
Platelet labeling. (CPT 78190-78191, 78199)
D. Miscellaneous Radiopharmaceuticals:
1. Chromium CR-51 Sodium Chromate, Diagnostic, per study dose, up to 250 microcuries A9553
RBC Mass (CPT 78120-78122)
RBC Survival (CPT 78130-78135, 78140)
Platelet Survival. (CPT 78190-78191)
2. Gallium Ga-67 Citrate, Diagnostic, per mCi A9556
Used in scans searching for infections, inflammation, tumors (CPT 78800-78807), and Sarcoidosis (CPT 78999)
3. Chromic Phosphate P-32, suspension, Therapeutic, per mCi A9564
Therapeutic imaging agent for treatment of ovarian cancer. (CPT 79200)
Interstitial radioactive colloid therapy. (CPT 79300, 79445)
4 Sodium Phosphate P-32, Therapeutic, per mCi A9563
Therapeutic imaging agent for treatment of polycythemia vera or thrombocythemia (CPT 79101)
5. Strontium SR-89 Chloride (Metastron®), Therapeutic, per mCi, A9600
Therapeutic for treatment of bone pain due to skeletal metastases. (CPT 79101)
6. Samarium SM-153 Lexidronam (Quadramet®) Therapeutic, per treatment dose up to 150 millicuries (A9604).
Therapeutic for the treatment of pain in patients with confirmed osteoblastic metastatic bone lesions that enhance on radionuclide bone scan (CPT 79101)
7. Thallous Chloride TL-201, diagnostic, per mCi, A9505
Cardiac imaging (CPT 78451-78454)
Parathyroid imaging (CPT 78070)
Tumor imaging (CPT 78800-78804)
Brain imaging (CPT 78607)
8. Xenon Xe-133 Gas, Diagnostic, per 10 mCi's, A9558
Lung study (CPT 78579, 78580, 78582, 78597, 78598)
E. Pet Scan radiopharmaceuticals (A9555, A9552, A9526):
The payment for the radio-tracer or radiopharmaceuticals will be reimbursed for pet scans.
1. Rubidium RB-82 (A9555)
2. Fluorodeoxyglucose (F-18 FDG) (A9552)
3. Ammonia N-13 (A9526)
F. The following agents are no longer marketed in the United States and will be denied. Coverage will be added if the agent(s) become available in the future.
1. A9501 Technetium Tc-99m Teboroxime (Cardiotec®)
2. A9504 Technetium Tc 99m Apcitide (Acu Tect®),
3. A9536 Technetium Tc-99M Depreotide, (Neotect®)
4. A9550 Technetium Tc-99m Sodium Gluceptate (Glucoheptonate®)
5. A9566 Technetium Tc-99m Fanolesomab, (NeutroSpec®)
6. A9546 Cobalt CO-57-/58 Cyanocobalamin
7. A9559 Cobalt CO-57 Cyanocobalamin, oral
G. Use of radiopharmaceuticals is regulated by the Nuclear Regulatory Commission (NRC) under strict procedures and guidelines. Persons administering radiopharmaceuticals should have either a license from the NRC or be credentialed by an institution having a broad license from the NRC
Coding Information
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 78000 - 79999 | THYROID UPTAKE; SINGLE DETERMINATION - RADIOPHARMACEUTICAL THERAPY, UNLISTED PROCEDURE |
| A4641 | RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED |
| A4642 | INDIUM IN-111 SATUMOMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 MILLICURIES |
| A9500 | TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE |
| A9502 | TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE |
| A9503 | TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES |
| A9505 | THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE |
| A9507 | INDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES |
| A9508 | IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 MILLICURIE |
| A9510 | TECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES |
| A9512 | TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE |
| A9516 | IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES |
| A9517 | IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIE |
| A9521 | TECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
| A9524 | IODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES |
| A9526 | NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES |
| A9527 | IODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE |
| A9528 | IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE |
| A9529 | IODINE I-131 SODIUM IODIDE SOLUTION, DIAGNOSTIC, PER MILLICURIE |
| A9530 | IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE |
| A9531 | IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES) |
| A9532 | IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES |
| A9537 | TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES |
| A9538 | TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
| A9539 | TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
| A9540 | TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES |
| A9541 | TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES |
| A9542 | INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES |
| A9543 | YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40 MILLICURIES |
| A9544 | IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE |
| A9545 | IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSE |
| A9547 | INDIUM IN-111 OXYQUINOLINE, DIAGNOSTIC, PER 0.5 MILLICURIE |
| A9548 | INDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 MILLICURIE |
| A9551 | TECHNETIUM TC-99M SUCCIMER, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES |
| A9552 | FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES |
| A9553 | CHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 250 MICROCURIES |
| A9554 | IODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MICROCURIES |
| A9555 | RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES |
| A9556 | GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE |
| A9557 | TECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
| A9558 | XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES |
| A9560 | TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES |
| A9561 | TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES |
| A9562 | TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES |
| A9563 | SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE |
| A9564 | CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER MILLICURIE |
| A9567 | TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75 MILLICURIES |
| A9568 | TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES |
| A9569 | TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE |
| A9570 | INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE |
| A9571 | INDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, DIAGNOSTIC, PER STUDY DOSE |
| A9572 | INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 MILLICURIES |
| A9582 | IODINE I-123 IOBENGUANE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES |
| A9584 | IODINE 1-123 IOFLUPANE, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES |
| A9600 | STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE |
| A9604 | SAMARIUM SM-153 LEXIDRONAM, THERAPEUTIC, PER TREATMENT DOSE, UP TO 150 MILLICURIES |
| C9898 | RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY |
Not Covered
| A9501 | TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSE |
| A9504 | TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES |
| A9536 | TECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 35 MILLICURIES |
| A9546 | COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE |
| A9550 | TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIE |
| A9559 | COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE |
| A9566 | TECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
ICD-9 Codes that Support Medical Necessity
| XX000 | Not Applicable |
Diagnoses that Support Medical Necessity
NA
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
Appendices
Utilization Guidelines
Up to 2 units of service will be allowed for A9500 and A9502.
One unit of service will be allowed for A9503
Claims reviewed for cardiac blood pool imaging / gated Equilibrium studies (78472, 78473, 78494, and 78496) were submitted with incorrect radiopharmaceutical codes. A9560 will be allowed for these procedure codes. A9538 and A9512 will be denied when billed with these CPT codes.
Sources of Information and Basis for Decision
Radiology and Nuclear Medicine physicians in the state of Wisconsin
Pub. 100-3, Ch.1, Part 4, Section 220.6 formerly Coverage Issues Manual 50-36, MCM 4173, PM-B-01-28; PM-AB-02-120
Society of Nuclear Medicine (SNM):
Practice Management Coding Corner:
1. Cardiac Blood Pool Imaging Radiopharmaceutical Codes
http://interactive.snm.org/index.cfm?PageID=2437&RPID=1995
2. Gastrointestinal Bleed Imaging Radiopharmaceutical Codes
http://interactive.snm.org/index.cfm?PageID=5018&RPID=1995
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from nuclear medicine and radiology.
Advisory Committee Meeting Notes
Wisconsin 09/24/2010
Illinois 09/22/2010
Michigan 09/15/2010
Minnesota 09/16/2010
Iowa, Kansas, Missouri, Nebraska 10/07/2010
Open Meeting: 09/02/2010
Start Date of Comment Period
Revision History Number
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
78000 descriptor was changed in Group 1
78001 descriptor was changed in Group 1
78007 descriptor was changed in Group 1
78018 descriptor was changed in Group 1
78102 descriptor was changed in Group 1
78103 descriptor was changed in Group 1
78104 descriptor was changed in Group 1
78110 descriptor was changed in Group 1
78111 descriptor was changed in Group 1
78120 descriptor was changed in Group 1
78121 descriptor was changed in Group 1
78190 descriptor was changed in Group 1
78268 descriptor was changed in Group 1
78271 descriptor was changed in Group 1
78272 descriptor was changed in Group 1
78300 descriptor was changed in Group 1
78305 descriptor was changed in Group 1
78306 descriptor was changed in Group 1
78315 descriptor was changed in Group 1
78350 descriptor was changed in Group 1
78351 descriptor was changed in Group 1
78451 descriptor was changed in Group 1
78452 descriptor was changed in Group 1
78453 descriptor was changed in Group 1
78454 descriptor was changed in Group 1
78458 descriptor was changed in Group 1
78472 descriptor was changed in Group 1
78473 descriptor was changed in Group 1
78481 descriptor was changed in Group 1
78483 descriptor was changed in Group 1
78491 descriptor was changed in Group 1
78492 descriptor was changed in Group 1
78494 descriptor was changed in Group 1
78586 descriptor was changed in Group 1
78587 descriptor was changed in Group 1
78591 descriptor was changed in Group 1
78593 descriptor was changed in Group 1
78594 descriptor was changed in Group 1
78700 descriptor was changed in Group 1
78709 descriptor was changed in Group 1
78800 descriptor was changed in Group 1
78801 descriptor was changed in Group 1
78802 descriptor was changed in Group 1
78804 descriptor was changed in Group 1
78805 descriptor was changed in Group 1
78806 descriptor was changed in Group 1
78811 descriptor was changed in Group 1
78812 descriptor was changed in Group 1
78813 descriptor was changed in Group 1
78814 descriptor was changed in Group 1
78815 descriptor was changed in Group 1
78816 descriptor was changed in Group 1
79005 descriptor was changed in Group 1
79101 descriptor was changed in Group 1
79200 descriptor was changed in Group 1
79300 descriptor was changed in Group 1
79440 descriptor was changed in Group 1
79445 descriptor was changed in Group 1
02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
05/17/2011 - Full Document Replacement for Draft being released to Final.
11/01/2011- Added C9406 or A4641 for Iodine I-123 ioflupane, (DaTscan) effective 01/14/2011; C9406- ASC and Hospital Outpatient department-code effective 07/01/2011.
11/21/2011 - The following CPT/HCPCS codes were added to these code ranges:
78226 was added to code range 78000 - 79999 in Group 1
78227 was added to code range 78000 - 79999 in Group 1
78579 was added to code range 78000 - 79999 in Group 1
78582 was added to code range 78000 - 79999 in Group 1
78597 was added to code range 78000 - 79999 in Group 1
78598 was added to code range 78000 - 79999 in Group 1
11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
78580 descriptor was changed in Group 1
11/21/2011 - The following CPT/HCPCS codes were deleted:
78220 was deleted from Group 1
78223 was deleted from Group 1
78584 was deleted from Group 1
78585 was deleted from Group 1
78586 was deleted from Group 1
78587 was deleted from Group 1
78588 was deleted from Group 1
78591 was deleted from Group 1
78593 was deleted from Group 1
78594 was deleted from Group 1
78596 was deleted from Group 1
C9406 was deleted from Group 1
01/01/2012- Code update-added A9584 & removed deleted code C9406 & removed A4641 for billing Iodine I-123 ioflupane.
03/01/2011- Article posted. Removed deleted codes 78220, 78223 & added CPT 78226, 78227. New codes effective 01/01/2012.
Article posted 05/01/2012- Removed deleted codes 78584-78596 & added 78579, 78582, 78597, 78598 to A9539, A9567, A9558 & added 78582, 78597, 78598 to A9540, A9524. These changes are effective 01/01/2012.
Reason for Change
Related Documents
LCD Attachments
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Page Last Updated: Thursday, 03-May-2012 11:11:45 CDT
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