Radiopharmaceuticals

Reimbursement Policy:
Radiopharmaceuticals

Effective Date:
June 1, 2011

Last Revised Date:
January 1, 2015

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

CodeAllow with Procedure Codes:Max # of Units

A950078451-784542

A950078070-78072, 78605-78607, 78800-788041

A950278451-784542

A950278070-78072, 788031

A950378300-783201

A950578451-78454, 78070-78072, 78800-78804, 786074

A950778800-788041

A950878075, 78800-788041

A950978012-78018, 78020, 78070-780725

A951078226, 782271

A951278012-78015, 78600-78607, 78610, 78481, 78483, 78261, 78290, 78291, 78070-78072, 78230-78232, 78730, 78740, 78630-78650, 78660, 78761Invoice required

A951678012-78018, 78020, 78070-780724

A952078195Invoice required

A952178600-78607, 786102

A952478110-78111, 78122, 78600-78607, 78610, 78579-78598, 78451-78454, 78800- 78804, 78472-78473, 78481-784835

A952878012-78018, 788038

A952978012-78018, 788038

A953178012-78018, 78803Invoice required

A953778226, 782271

A953878300-78320,78466-784691

A953978579-78598, 78761, 78700-78725, 78730, 78740, 78630-78650, 78600-78607, 78610, 78291, 78645, 78481, 78483, 78445, 784281

A954078579-78598, 78291,78216, 78428, 78201, 78205, 78215, 78800, 78801, 788031

A954178201-78216, 78185, 78278, 78102-78104, 78264, 78258, 78262, 78740, 78730, 78195, 782911

A9542788041

A9544788041

A954778805-78807, 78185, 78190-7819171

A954878630, 78635, 78645, 78647, 78650, 788001

A955178700-78710, 78800-788041

A955378120-78122, 78130-78135, 78140, 78190-781911

A955478707-78709, 787251

A955678800-788075

A955778600-78607, 786101

A955878579-785983

A956078472, 78473, 78494, 78496, 78278, 78201-78206, 78445, 78457-78458, 78215, 78216, 781851

A956178300-783201

A956278700-787251

A956778579-785981

A956978805-788071

A957078805-78807, 781851

A957178190-781911

A957278075, 78015-78018, 78800-78804,1

A958278075, 78800-788041

Policy 047_v2.0_01012015