RADIOPHARMACEUTICALS AND CONTRAST MEDIA

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1 CLINICAL POLICY RADIOPHARMACEUTICALS AND CONTRAST MEDIA Policy Number: RADIOLOGY T0 Effective Date: April 1, 2016 Table of Contents CONDITIONS OF COVERAGE... COVERAGE RATIONALE... DEFINITIONS... BACKGROUND... APPLICABLE CODES... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Page Related Policies: Refer to the Coverage Rationale section below for a list of related policies. The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Applicable Lines of Business/Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership. General benefits package No Yes 1 No Outpatient, Office 1 When a radiology, radiation therapy or cardiology service requires precertification, a separate authorization is not needed for the radiopharmaceuticals and/or contrast media. 1

2 COVERAGE RATIONALE evicore Healthcare administers claims on behalf of Oxford Health Plans for the following services that may be billed in conjunction with radiopharmaceuticals and/or contrast media: Radiology Services: Refer to Radiology Procedures Requiring Precertification for evicore Healthcare Arrangement for additional information. Radiation Therapy Services: Refer to Radiation Therapy Procedures Requiring Precertification for evicore Healthcare Arrangement for additional information. Cardiology Services: Refer to Cardiology Procedures Requiring Precertification for evicore Healthcare Arrangement for additional information. Reimbursement Guidelines MRI: Contrast agents billed with an MRI will be denied as included in the primary procedure PET Scans: Radiopharmaceutical billed with a PET scan will be denied as included in the primary procedure CT or other radiographic study: Any code not on the list below or billed without a procedure code from the covered list below will deny as included in the primary procedure Radiopharmaceuticals Billed in Conjunction with Nuclear Medicine Procedures evicore Healthcare will reimburse for covered radioisotopes when used in conjunction with a nuclear medicine procedure. The radiopharmaceutical can be administered up to 96 hours before the primary procedure. Covered services will be processed according to the chart below. Code Code Description Allow with Procedure Codes: Technetium Tc-99m, Sestamibi, diagnostic, per study A dose , A902 A903 A90 A907 A908 A909 A910 Technetium Tc-99m tetrofosmin, diagnostic, per study dose Technetium Tc-99m, Medronate, (MDP), diagnostic, per study dose, up to 30 Thallous Chloride TL-201, diagnostic, per mci Indium IN 111 Capromab Pendetide (ProstaScintâ) per study dose, up to 10 mci's Iobenguane sulfate-metaiodobenzyl guanidine (MIBG) per 0. mci Iodine I-123 Sodium Iodide, diagnostic, per millicurie Technetium Tc-99 Disofenin (Hepatolite DISIDA), per study dose, up to 1 mci s , , 78020, ,

3 Code Code Description Allow with Procedure Codes: 78481, A Technetium Tc-99m-Pertechnetate, Diagnostic, per mci A916 Iodine I-123 Sodium iodide capsule(s), Diagnostic, A921 A924 A920 A928 A929 A931 A937 A938 A939 A940 per 100 Microcuries, up to 999 microcuries Technetium Tc-99m Exametazine (Ceretec ), Diagnostic, per study dose, up to 2 mci s Iodinated I-131-Serum Albumin, diagnostic, per microcuries Technetium TC-99m, tilmanocept, diagnostic, up to 0. millicurie Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mci Iodine I-131 Sodium Iodide solution, Diagnostic, per mci Iodine I-131 Sodium Iodide, Diagnostic, per microcurie (up to 100 microcuries) Technetium Tc-99m Mebrofenin (Choletec ) Diagnostic, per study dose, up to 1 Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite ) Diagnostic, per study dose, up to 2 Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 2 Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mci s , , , , , , , 7820, , 78801,

4 Code Code Description Allow with Procedure Codes: A941 Technetium Tc-99m Sulfur Colloid, Diagnostic, per 78264, 7826, study dose, up to , A942 Indium-IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to A944 Iodine I-131 Tositumomab, (Bexxar ) Diagnostic, per study dose A947 Indium-IN-111 Oxyquinoline, Diagnostic, per 0. mci , 7818 A948 A91 A93 Indium IN-111 Pentetate (MyoScint ) Diagnostic, per 0. mci Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 Chromium CR-1 Sodium Chromate, Diagnostic, per study dose, up to 20 microcuries , 7863, 7864, , A94 Iodine-12 Sodium Iothalamate (Glofil-12 ), Diagnostic, per study dose, up to 10 microcuries , 7872 A96 Gallium Ga-67 Citrate, Diagnostic, per mci A97 Technetium Tc-99m Bicisate (Neurolite ), Diagnostic, per study dose, up to 2 A98 Xenon Xe-133 Gas, Diagnostic, per 10 mci s A960 A961 A962 A967 A969 A970 A971 A972 Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mci s (Ultra Tag or cold pyrophosphate (pyp) +99m technetium) Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 1 Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 7 mci s Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose Indium-111 labeled autologous white blood cells, diagnostic, per study dose Indium in-111 labeled autologous platelets, diagnostic, per study dose Indium-111 Pentetreotide (OctreoScan ), Diagnostic, per study dose, up to , 78473, 78494, , 78216, , ,,

5 Code Code Description Allow with Procedure Codes: Iodine i-123 Iobenguane, diagnostic, per study 7807 A982 dose, up to 1 AdreView ) DEFINITIONS Radiopharmaceutical Material: A radioactive pharmaceutical, nuclide, or other chemical used for diagnostic or therapeutic purposes. BACKGROUND The purpose of this policy is to outline Oxford's reimbursement of radiopharmaceuticals and contrast media provided by participating providers in conjunction with eligible nuclear medicine procedures. APPLICABLE CODES The Current Procedural Terminology (CPT ) codes and/or Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the member specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive. Reimbursable HCPCS Codes (payable with a nuclear medicine procedure) HCPCS Code A4641 A4642 A900 A901 A902 A903 A904 A90 A907 A909 A910 A912 A916 A920 A921 A924 A928 A929 A931 A932 A937 A938 Description of Non-Ionic, Low Osmolar Contrast Radiopharmaceutical, diagnostic, not otherwise classified Indium-111 Satumomab pendetide, diagnostic, per study dose, up to 6 mci's Technetium Tc-99m, Sestamibi, diagnostic, per study dose Technetium Tc-99m Teboroxime (Cardiotec ) Technetium Tc-99m tetrofosmin, diagnostic, per study dose Technetium Tc-99m, Medronate, (MDP), diagnostic, per study dose, up to 30 Technetium Tc 99m Apcitide (Acu Tect Thallous Chloride TL-201, diagnostic, per mci Indium IN 111 Capromab Pendetide (ProstaScintâ) per study dose, up to 10 mci's Iodine I-123 Sodium Iodide, diagnostic, per millicurie Technetium Tc-99m disofenin, diagnostic, per study dose, up to 1 (Code Price is per vial) Technetium Tc-99m-Pertechnetate, Diagnostic, per mci Iodine I-123 Sodium iodide capsule(s), Diagnostic per 100 Microcuries, up to 999 microcuries Technetium Tc-99m, tilmanocept, diagnostic. I[ tp 0. millicure Technetium Tc-99m Exametazine (Ceretec ), Diagnostic, per study dose, up to 2 mci s Iodinated I-131-Serum Albumin, diagnostic, per microcuries Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mci Iodine I-131 Sodium Iodide solution, Diagnostic, per mci Iodine I-131 Sodium Iodide, Diagnostic, per microcurie (up to 100 microcuries) Iodine I-12 serum albumin, diagnostic, per microcuries Technetium Tc-99m Mebrofenin (Choletec ) Diagnostic, per study dose, up to 1 Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite ) Diagnostic, per study dose, up to 2

6 HCPCS Code A939 A940 A941 A942 A944 A947 A948 A91 A93 A94 A96 A97 A98 A960 A961 A962 A967 A968 A969 A970 A971 A972 A982 Description of Non-Ionic, Low Osmolar Contrast Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 2 Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mci s Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to20 Indium-IN-111 Ibritumomab Tiuxetan, Diagnostic, per study dose, up to Iodine I-131 Tositumomab, (Bexxar ) Diagnostic, per study dose Indium-IN-111 Oxyquinoline, Diagnostic, per 0. mci Indium IN-111 Pentetate (MyoScint ) Diagnostic, per 0. mci Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 Chromium CR-1 Sodium Chromate, Diagnostic, per study dose, up to 20 microcuries Iodine-12 Sodium Iothalamate (Glofil-12 ), Diagnostic, per study dose, up to 10 microcuries Gallium Ga-67 Citrate, Diagnostic, per mci Technetium Tc-99m Bicisate (Neurolite ), Diagnostic, per study dose, up to 2 Xenon Xe-133 Gas, Diagnostic, per 10 mci s Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mci s (Ultra Tag or cold pyrophosphate (pyp) +99m technetium) Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 1 Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 7 mci s Technetium TC-99m arcitumomab, diagnostic, per study dose, up to 4 Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose Indium-111 labeled autologous white blood cells, diagnostic, per study dose Indium in-111 labeled autologous platelets, diagnostic, per study dose Indium-111 Pentetreotide (OctreoScan ), Diagnostic, per study dose, up to 6 Iodine i-123 Iobenguane, diagnostic, per study dose, up to 1 AdreView ) Non-Reimbursable HCPCS Codes (the cost of contrast material is considered part of the underlying examination) HCPCS Code A926 A936 A946 A90 A92 A9 A99 A966 A976 A977 A978 Description of Ionic, High Osmolar Contrast Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 3 Cobalt Co-7/8, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 2 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 4 Rubidium Rb-82, diagnostic, per study dose, up to 60 Cobalt Co-7 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 2 Injection, gadoteridol Injection, gadobenate dimeglumine Injection, gadobenate dimeglumine 6

7 HCPCS Code Description of Ionic, High Osmolar Contrast A979 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified A980 Sodium fluoride F-18, diagnostic, per study dose, up to 30 A981 Injection, gadoxetate disodium, 1 ml A983 Injection, gadofosveset trisodium, 1 m A984* Iodine I -123 ioflupane, diagnostic, per study dose, up to A98 Injection, gadobutrol, 0.1 ml A986 Florbetapir f18, diagnostic, per study dose, up to 10 A9698 Non-radioactive contrast imaging material, not otherwise classified, per study A9700 Supply of injectable contrast material for use in echocardiography Q991 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml Q993 Injection, iron-based magnetic resonance contrast agent, per ml ( Q994 Oral magnetic resonance contrast agent, per 100 ml Q998 High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml Q999 High osmolar contrast material, mg/ml iodine concentration, per ml Q9960 High osmolar contrast material, mg/ml iodine concentration, per ml Q9961 High osmolar contrast material, mg/ml iodine concentration, per ml Q9962 High osmolar contrast material, mg/ml iodine concentration, per ml Q9963 High osmolar contrast material, mg/ml iodine concentration, per ml Q9964 High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml Q996 Low osmolar contrast material, mg/ml iodine concentration, per ml Q9966 Low osmolar contrast material, mg/ml iodine concentration, per ml Q9967 Low osmolar contrast material, mg/ml iodine concentration, per ml Q9968 Injection, non-radioactive, non-contrast, visualization adjunct (e.g., Methylene Blue, Isosulfan Blue), 1 mg *A984 used in conjunction with (SPECT) brain imaging (CPT 78607) is considered investigational and will be denied. REFERENCES 1. American Medical Association. Healthcare Common Procedure Coding System. Medicare's National Level II Codes HCPCS. 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services. POLICY HISTORY/REVISION INFORMATION Date 04/01/2016 Action/Description Revised reimbursement guidelines; added CPT codes 7826 and to list of procedure codes allowed with A941 Archived previous policy version RADIOLOGY T0 7

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