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COVID-19

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
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