Radiopharmaceuticals
Reimbursement Policy:
Radiopharmaceuticals
Effective Date:
June 1, 2011
Last Revised Date:
August 16, 2021
Purpose:
This policy outlines Horizon BCBSNJ’s reimbursement policy for radiopharmaceuticals and contrast material.
Scope:
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- FEP
- ITS Home
All Insured and Administrative Services Only (ASO) accounts are included.
Policy:
All professional providers will be reimbursed based on this policy for the procedures and number of units listed in Attachment A. Guidelines are based on usual, customary and appropriate utilization and billing practice for the office setting and outpatient places of service.
Procedure:
All radiopharmaceutical diagnostic imaging isotopes or agents used in the performance of diagnostic nuclear medicine procedures will be reimbursed according to the coding chart below.
- The radiopharmaceutical may be administered up to 96 hours before the primary procedure.
- Isotopes administered for therapeutic purposes will be subject to member’s benefits and contract exclusions and guidelines.
Contrast agents billed with an MRI will be denied.
Radiopharmaceutical billed with a PET scan will be denied.
CT or other radiographic studies, if not indicated on coding chart below, will be denied.
Non-ionic contrasts, also referred to as low osmolar contrast material (LOCM), will be denied.
A9584: Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries (DaTscan), used in conjunction with (SPECT) brain imaging (CPT 78607), is considered investigational and will be denied.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
Coding Chart:
Diagnostic radiopharmaceuticals will be reimbursed according to the information within the table below. The radiopharmaceuticals administered up to 96 hours before the primary procedure will be subject to these rules.
Code |
Allow with Code(s) |
Max Units |
A4641 |
n/a |
Invoice Required |
A9500 |
78012-78016, 78018 |
1 |
A9500 |
78070-78072 |
1 |
A9500 |
78075 |
1 |
A9500 |
78099 |
1 |
A9500 |
78428 |
2 |
A9500 |
78445 |
1 |
A9500 |
78451-78454 |
2 |
A9500 |
78456-78458, 78466-78483, 78494-78496 |
2 |
A9500 |
78499 |
2 |
A9500 |
78605-78606, 78800-78804, 78808 |
1 |
A9500 |
78830-78832 |
1 |
A9500 |
78999 |
1 |
A9502 |
78012-78016, 78018 |
2 |
A9502 |
78070-78072 |
2 |
A9502 |
78075 |
2 |
A9502 |
78099 |
2 |
A9502 |
78428 |
2 |
A9502 |
78445 |
2 |
A9502 |
78451-78454 |
2 |
A9502 |
78456-78458, 78466-78483, 78494-78496 |
2 |
A9502 |
78499 |
2 |
A9502 |
78800-78804, 78808 |
2 |
A9502 |
78830-78832 |
2 |
A9502 |
78999 |
2 |
A9503 |
78300, 78305, 78306 |
1 |
A9503 |
78315 |
1 |
A9503 |
78350, 78351 |
1 |
A9503 |
78399 |
1 |
A9503 |
78803 |
1 |
A9505 |
78070-78072 |
4 |
A9505 |
78075 |
4 |
A9505 |
78099 |
4 |
A9505 |
78414 |
4 |
A9505 |
78428 |
4 |
A9505 |
78445 |
4 |
A9505 |
78451-78454 |
4 |
A9505 |
78456-78458, 78466-78483, 78494-78496 |
4 |
A9505 |
78499 |
4 |
A9505 |
78800-78804, 78808 |
4 |
A9505 |
78830-78832 |
4 |
A9505 |
78999 |
4 |
A9507 |
78800-78804 |
1 |
A9507 |
78830-78832 |
1 |
A9507 |
78999 |
1 |
A9510 |
78201, 78202 |
1 |
A9510 |
78215, 78216 |
1 |
A9510 |
78226, 78227 |
1 |
A9510 |
78230-78232 |
1 |
A9510 |
78258 |
1 |
A9510 |
78261 |
1 |
A9510 |
78262 |
1 |
A9510 |
78264-78266 |
1 |
A9510 |
78267, 78268 |
1 |
A9510 |
78278 |
1 |
A9510 |
78282 |
1 |
A9510 |
78290 |
1 |
A9510 |
78291 |
1 |
A9510 |
78299 |
1 |
A9512 |
78012-78015 |
10 |
A9512 |
78016, 78018 |
10 |
A9512 |
78070-78072 |
10 |
A9512 |
78075 |
10 |
A9512 |
78099 |
10 |
A9512 |
78102-78104 |
10 |
A9512 |
78110, 78111 |
10 |
A9512 |
78120, 78121 |
10 |
A9512 |
78122 |
10 |
A9512 |
78130 |
10 |
A9512 |
78140 |
10 |
A9512 |
78185 |
10 |
A9512 |
78191 |
10 |
A9512 |
78195 |
10 |
A9512 |
78199 |
10 |
A9512 |
78201, 78202 |
10 |
A9512 |
78215, 78216 |
10 |
A9512 |
78226, 78227 |
10 |
A9512 |
78230-78232 |
10 |
A9512 |
78258 |
10 |
A9512 |
78261 |
10 |
A9512 |
78262 |
10 |
A9512 |
78264-78266 |
10 |
A9512 |
78267, 78268 |
10 |
A9512 |
78278 |
10 |
A9512 |
78282 |
10 |
A9512 |
78290 |
10 |
A9512 |
78291 |
10 |
A9512 |
78299 |
10 |
A9512 |
78481, 78483 |
10 |
A9512 |
78600-78606, 78610 |
10 |
A9512 |
78630, 78635, 78645, 78650 |
10 |
A9512 |
78660 |
10 |
A9512 |
78699 |
10 |
A9512 |
78700, 78701, 78707-78709, 78725 |
10 |
A9512 |
78730 |
10 |
A9512 |
78740 |
10 |
A9512 |
78761 |
10 |
A9512 |
78799 |
10 |
A9512 |
78803 |
10 |
A9516 |
78012-78014 |
4 |
A9516 |
78015 78016 78018 |
4 |
A9516 |
78070-78072 |
4 |
A9516 |
78075 |
4 |
A9516 |
78099 |
4 |
A9520 |
78102-78104 |
1 |
A9520 |
78110, 78111 |
1 |
A9520 |
78120, 78121 |
1 |
A9520 |
78122 |
1 |
A9520 |
78130 |
1 |
A9520 |
78140 |
1 |
A9520 |
78185 |
1 |
A9520 |
78191 |
1 |
A9520 |
78195 |
1 |
A9520 |
78199 |
1 |
A9521 |
78600-78606, 78610 |
2 |
A9521 |
78630, 78635, 78645, 78650 |
2 |
A9521 |
78660 |
2 |
A9521 |
78699 |
2 |
A9521 |
78803 |
1 |
A9524 |
78102-78104 |
10 |
A9524 |
78110-78111, 78122 |
10 |
A9524 |
78120, 78121 |
10 |
A9524 |
78130 |
10 |
A9524 |
78140 |
10 |
A9524 |
78185 |
10 |
A9524 |
78191 |
10 |
A9524 |
78195 |
10 |
A9524 |
78199 |
10 |
A9524 |
78451, 78453, 78454 |
10 |
A9524 |
78579-78598 |
10 |
A9524 |
78600-78606, 78610 |
10 |
A9524 |
78800-78804 |
10 |
A9524 |
78472-78473, 78481 |
10 |
A9528 |
78012-78018, 78803 |
10 |
A9528 |
78070-78072 |
10 |
A9528 |
78075 |
10 |
A9528 |
78099 |
10 |
A9529 |
78012-78018, 78803 |
10 |
A9529 |
78070-78072 |
10 |
A9529 |
78075 |
10 |
A9529 |
78099 |
10 |
A9531 |
78012-78018, 78803 |
80 |
A9531 |
78070-78072 |
80 |
A9531 |
78075 |
80 |
A9531 |
78099 |
80 |
A9537 |
78226, 78227 |
1 |
A9537 |
78201, 78202 |
1 |
A9537 |
78215, 78216 |
1 |
A9537 |
78230-78232 |
1 |
A9537 |
78258 |
1 |
A9537 |
78261 |
1 |
A9537 |
78262 |
1 |
A9537 |
78264-78266 |
1 |
A9537 |
78267, 78268 |
1 |
A9537 |
78278 |
1 |
A9537 |
78282 |
1 |
A9537 |
78290 |
1 |
A9537 |
78291 |
1 |
A9537 |
78299 |
1 |
A9538 |
78300, 78306, 78315 |
1 |
A9538 |
78305 |
1 |
A9538 |
78350, 78351 |
1 |
A9538 |
78399 |
1 |
A9538 |
78466-78469 |
1 |
A9538 |
78999 |
1 |
A9538 |
78414 |
1 |
A9538 |
78428 |
1 |
A9538 |
78445 |
1 |
A9538 |
78451, 78452, 78453, 78454 |
1 |
A9538 |
78456-78458 |
1 |
A9538 |
78472, 78473, 78481, 78483, 78494, 78496 |
1 |
A9538 |
78499 |
1 |
A9538 |
78803 |
1 |
A9539 |
78291, 78645 |
1 |
A9539 |
78428 |
1 |
A9539 |
78445 |
1 |
A9539 |
78481, 78483 |
1 |
A9539 |
78579, 78580, 78582, 78597, 78598 |
1 |
A9539 |
78599 |
1 |
A9539 |
78600-78606, 78610 |
1 |
A9539 |
78630-78650 |
1 |
A9539 |
78660 |
1 |
A9539 |
78699 |
1 |
A9539 |
78700, 78701, 78707-78709, 78725 |
1 |
A9539 |
78730 |
1 |
A9539 |
78740 |
1 |
A9539 |
78761 |
1 |
A9539 |
78799 |
1 |
A9539 |
78803 |
1 |
A9540 |
78201, 78215 |
1 |
A9540 |
78216, 78428 |
1 |
A9540 |
78291 |
1 |
A9540 |
78579, 78580, 78582, 78597, 78598 |
1 |
A9540 |
78599 |
1 |
A9540 |
78800, 78801, 78803 |
1 |
A9541 |
78102-78104 |
1 |
A9541 |
78110, 78111 |
1 |
A9541 |
78120, 78121 |
1 |
A9541 |
78122 |
1 |
A9541 |
78130 |
1 |
A9541 |
78140 |
1 |
A9541 |
78185 |
1 |
A9541 |
78191 |
1 |
A9541 |
78195 |
1 |
A9541 |
78199 |
1 |
A9541 |
78201-78202, 78215-78216 |
1 |
A9541 |
78226, 78227 |
1 |
A9541 |
78230-78232 |
1 |
A9541 |
78261 |
1 |
A9541 |
78258, 78262 |
1 |
A9541 |
78264, 78265, 78266 |
1 |
A9541 |
78267, 78268 |
1 |
A9541 |
78278 |
1 |
A9541 |
78282 |
1 |
A9541 |
78290 |
1 |
A9541 |
78291 |
1 |
A9541 |
78299 |
1 |
A9541 |
78730 |
1 |
A9541 |
78740 |
1 |
A9547 |
78185 |
1 |
A9547 |
78191 |
1 |
A9547 |
78199 |
1 |
A9547 |
78800-78804 |
1 |
A9547 |
78808 |
1 |
A9547 |
78830-78832 |
1 |
A9547 |
78999 |
1 |
A9548 |
78102-78104 |
1 |
A9548 |
78110, 78111 |
1 |
A9548 |
78120, 78121 |
1 |
A9548 |
78122 |
1 |
A9548 |
78130 |
1 |
A9548 |
78140 |
1 |
A9548 |
78185 |
1 |
A9548 |
78191 |
1 |
A9548 |
78195 |
1 |
A9548 |
78199 |
1 |
A9548 |
78201, 78202 |
1 |
A9548 |
78215, 78216 |
1 |
A9548 |
78226, 78227 |
1 |
A9548 |
78230-78232 |
1 |
A9548 |
78258 |
1 |
A9548 |
78261 |
1 |
A9548 |
78262 |
1 |
A9548 |
78264-78266 |
1 |
A9548 |
78267, 78268 |
1 |
A9548 |
78278 |
1 |
A9548 |
78282 |
1 |
A9548 |
78290 |
1 |
A9548 |
78291 |
1 |
A9548 |
78299 |
1 |
A9548 |
78600, 78601, 78605, 78606, 78610 |
1 |
A9548 |
78630, 78635,78645 |
1 |
A9548 |
78650 |
1 |
A9548 |
78660 |
1 |
A9548 |
78699 |
1 |
A9548 |
78800 |
1 |
A9548 |
78803 |
1 |
A9551 |
78700-78709 |
1 |
A9551 |
78725 |
1 |
A9551 |
78730 |
1 |
A9551 |
78740 |
1 |
A9551 |
78761 |
1 |
A9551 |
78799 |
1 |
A9551 |
78800, 78802, 78803, 78804 |
1 |
A9554 |
78700, 78701, 78725 |
1 |
A9554 |
78707-78709 |
1 |
A9554 |
78730 |
1 |
A9554 |
78740 |
1 |
A9554 |
78761 |
1 |
A9554 |
78799 |
1 |
A9556 |
78808 |
5 |
A9556 |
78830-78832 |
5 |
A9556 |
78999 |
5 |
A9556 |
78800-78804 |
5 |
A9557 |
78600-78606, 78610 |
2 |
A9557 |
78630, 78635, 78645, 78650 |
2 |
A9557 |
78660 |
2 |
A9557 |
78699 |
2 |
A9557 |
78803 |
2 |
A9558 |
78579-78598 |
3 |
A9558 |
78599 |
3 |
A9560 |
78201-78202 |
1 |
A9560 |
78215, 78216, 78185 |
1 |
A9560 |
78226, 78227 |
1 |
A9560 |
78230-78232 |
1 |
A9560 |
78258 |
1 |
A9560 |
78261 |
1 |
A9560 |
78262 |
1 |
A9560 |
78264-78266 |
1 |
A9560 |
78267, 78268 |
1 |
A9560 |
78472, 78473, 78494, 78496 |
1 |
A9560 |
78282 |
1 |
A9560 |
78290 |
1 |
A9560 |
78291 |
1 |
A9560 |
78299 |
1 |
A9560 |
78300, 78305, 78306, 78315 |
1 |
A9560 |
78350, 78351 |
1 |
A9560 |
78399 |
1 |
A9560 |
78414 |
1 |
A9560 |
78428 |
1 |
A9560 |
78451-78454 |
1 |
A9560 |
78456 |
1 |
A9560 |
78466-78469 |
1 |
A9560 |
78481, 78483, 78496 |
1 |
A9560 |
78499 |
1 |
A9560 |
78803 |
1 |
A9561 |
78300-78315 |
1 |
A9561 |
78350, 78351 |
1 |
A9561 |
78399 |
1 |
A9561 |
78803 |
1 |
A9562 |
78700-78725 |
1 |
A9562 |
78730 |
1 |
A9562 |
78740 |
1 |
A9562 |
78761 |
1 |
A9562 |
78799 |
1 |
A9562 |
78803 |
1 |
A9567 |
78579-78598 |
1 |
A9567 |
78599 |
1 |
A9569 |
78800-78803 |
1 |
A9569 |
78804 |
1 |
A9569 |
78808 |
1 |
A9569 |
78830-78832 |
1 |
A9569 |
78999 |
1 |
A9570 |
78185 |
1 |
A9570 |
78800- 78803 |
1 |
A9570 |
78804 |
1 |
A9570 |
78808 |
1 |
A9570 |
78830-78832 |
1 |
A9570 |
78999 |
1 |
A9571 |
78191 |
1 |
A9571 |
78199 |
1 |
A9571 |
78800-78804 |
1 |
A9571 |
78808 |
1 |
A9571 |
78830-78832 |
1 |
A9571 |
78835 |
1 |
A9571 |
78999 |
1 |
A9572 |
78075 |
1 |
A9572 |
78015-78018 |
1 |
A9572 |
78800-78804 |
1 |
A9572 |
78808 |
1 |
A9572 |
78830-78832 |
1 |
A9572 |
78999 |
1 |
A9582 |
78075 |
1 |
A9582 |
78800-78804 |
1 |
A9582 |
78012-78016, 78018, 78070-78072 |
1 |
A9582 |
78099 |
1 |
A9582 |
78428 |
1 |
A9582 |
78414 |
1 |
A9582 |
78445 |
1 |
A9582 |
78456, 78457, 78458 |
1 |
A9582 |
78451-78454, 78466-78469 |
1 |
A9582 |
78472-78483, 78494, 78496 |
1 |
A9582 |
78499 |
1 |
A9582 |
78808 |
1 |
A9582 |
78830-78832 |
1 |
A9582 |
78999 |
1 |
A9584 |
78600-78610 |
1 |
A9584 |
78630-78645 |
1 |
A9584 |
78650 |
1 |
A9584 |
78660 |
1 |
A9584 |
78699 |
1 |
A9584 |
78803 |
1 |
PET Scans
All radiopharmaceuticals billed with a PET scan will be denied as “included in the primary procedure. Isotopes administered for therapeutic purposes will be subject to member benefits, contract exclusions and guidelines.
Codes Considered Inclusive to an Imaging Service
Reimbursement for the services represented by the HCPCS codes below is considered included in the reimbursement for the radiology/cardiology imaging service performed.
- Contrast agents billed in conjunction with an MRI.
- Radiopharmaceuticals billed in conjunction with a PET scan.
- Materials billed with a CT or other radiographic study not mentioned above.
- Non-Ionic Contrasts or low osmolar contrast material.
- Isotopes for therapeutic purposes are not covered under these payment rules.
Code |
Code Description |
A9515 |
Choline c-11, diagnostic, per study dose up to 20 millicuries |
A9526 |
Nitrogen n-13 ammonia, diagnostic, per study dose, up to 40 millicuries |
A9552 |
Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries |
A9555 |
Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries |
A9575 |
Injection, gadoterate meglumine, 0.1 ml |
A9576 |
Injection, gadoteridol, (prohance multipack), per ml |
A9577 |
Injection, gadobenate dimeglumine (multihance), per ml |
A9578 |
Injection, gadobenate dimeglumine (multihance multipack), per ml |
A9579 |
Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS |
A9580 |
Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries |
A9581 |
Injection, gadoxetate disodium, 1 ml |
A9585 |
Injection, gadobutrol, 0.1 ml |
A9586 |
Florbetapir f18, diagnostic, per study dose, up to 10 millicuries |
A9587 |
Gallium ga-68, dotatate, diagnostic, 0.1 millicurie |
A9588 |
Fluciclovine f-18, diagnostic, 1 millicurie |
A9597 |
Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified |
A9598 |
Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified |
A9698 |
Non-radioactive contrast imaging material, noc, per study |
A9700 |
Supply of injectable contrast material for use in echocardiography, per study |
Q9951 |
Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml |
Q9953 |
Injection, iron-based magnetic resonance contrast agent |
Q9954 |
Oral magnetic resonance contrast agent, per ml |
Q9957 |
Injection, perflutren lipid microspheres, per ml |
Q9958 |
High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml |
Q9959 |
High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml |
Q9960 |
High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml |
Q9961 |
High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml |
Q9963 |
High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml |
Q9965 |
Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml |
Q9966 |
Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml |
Q9967 |
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
Q9968 |
Methylene blue, isosulfan blue), 1 mg |
Q9982 |
Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries |
Q9983 |
Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries |
Codes are Active/Invoice is Required
For the codes below, no product has been on the market for over 2 years. These codes will require an invoice.
Code |
Code Description |
A9501 |
Technetium tc-99m teboroxime, diagnostic, per study dose |
A9504 |
Technetium tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries |
A9508 |
Iobenguane sulfate-Metaiodobenzyl guanidine (MIBG) per 0.5 mCi |
A9509 |
Iodine I-123 Sodium Iodide, diagnostic, per millicurie |
A9532 |
Iodine i-125 serum albumin, diagnostic, per 5 microcuries |
A9536 |
Technetium tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries |
A9542 |
Indium-IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to 5 mCi's |
A9550 |
Technetium tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicurie |
A9553 |
Chromium CR-51 Sodium Chromate, Diagnostic, per study dose, up to 250 microcuries |
A9566 |
Technetium tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries |
A9568 |
Technetium tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries |
A9583 |
Injection, gadofosveset trisodium, 1 ml |
Q9962 |
High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml |
Q9964 |
High osmolar contrast material, 400 or greater mg/ml iodine concentration, per |
History:
6/2011: Policy Approved
1/1/2015: Combined Contrast Media & Radiopharmaceutical policies; Formatted in approved template.
03/25/2019: A9509, A9542, A9553 updated to invoice required; 78190 removed (termed 12/2017)
8/16/2020: Formatted code tables.
Policy 047_v3.0_03262019