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).
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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 78483	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