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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

Code Allow with procedure codes Max #Units
A9500 78070-78072, 78605-78607, 78800-78804 1
A9500 78451-78454 2
A9502 78070-78072, 78803 1
A9502 78451-78454 2
A9503 78300-78320 1
A9505 78070-78072, 78451-78454, 78607, 78800-78804 4
A9507 78800-78804 1
A9508 78075, 78800-78804 1
A9509 78012-78018, 78020, 78070-78072 invoice required
A9510 78226, 78227 1
A9512 78261, 78290, 78291, 78660, 78730, 78740, 78761, 78012- 78015, 78070-78072, 78230-78232, 78481, 78483, 78600-78607, 78610,78630-78650 invoice required
A9516 78012-78018, 78020, 78070-78072 4
A9520 78195 invoice required
A9521 78600-78607, 78610 2
A9524 78110-78111, 78122, 78451-78454, 78472-78473, 78481-78483, 78579-78598, 78600-78607, 78610, 78800-78804 5
A9528 78012-78018, 78803 8
A9529 78012-78018, 78803 8
A9531 78012-78018, 78803 invoice required
A9537 78226, 78227 1
A9538 78300-78320, 78466-78469 1
A9539 78428, 78445, 78730, 78740, 78761, 78291, 78645, 78481, 78483, 78579-78598, 78600-78607, 78610, 78630-78650, 78700-78725 1
A9540 78291, 78201, 78205, 78215, 78216, 78428, 78579-78598, 78800, 78801, 78803 1
A9541 78185, 78195, 78264, 78278, 78291, 78730, 78740, 78102-78104, 78201-78216, 78258, 78262 1
A9542 78804 invoice required
A9544 78804 1
A9547 78185, 78191, 78805-78807 1
A9548 78630, 78635, 78645,78647, 78650, 78800 1
A9551 78700-78710, 78800-78804 1
A9553 78120-78122, 78130-78135, 78140, 78191 invoice required
A9554 78707-78709, 78725 1
A9556 78800-78807 5
A9557 78600-78607, 78610 1
A9558 78579-78598 3
A9560 78185, 78201-78206, 78215, 78216, 78278, 78445, 78457-78458, 78472, 78473, 78494, 78496 1
A9561 78300-78320 1
A9562 78700-78725 1
A9567 78579-78598 1
A9569 78805-78807 1
A9570 78805-78807, 78185 1
A9571 78191 1
A9572 78015-78018, 78075, 78800-78804 1
A9582 78075, 78800-78804 1

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