Radiopharmaceuticals

Reimbursement Policy:
Radiopharmaceuticals

Effective Date:
June 1, 2011

Last Revised Date:
March 25, 2019

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

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)

Policy 047_ v3.0_03262019