MEDICAL POLICY POLICY TITLE ABORTION (SURGICAL AND MEDICAL) POLICY NUMBER MP I. POLICY

Transcription

1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): May 24, 2011 Effective Date: June 1, RETIRED I. POLICY Elective Abortion An elective abortion (including the abortion pill Mifepristone, also known as RU-486) may be considered medically necessary up to the period of legal viability as defined by the state law in which the member resides. An abortion may be considered medically necessary for the following indications: 1. When abortion is necessary to avert the death of the mother; 2. When abortion is performed in a case of pregnancy which is the result of rape reported within seventy-two (72) hours to a law enforcement agent; or 3. When abortion is performed in a case of pregnancy that is the result of incest that is reported within seventy-two (72) hours from the date when the female first learns she is pregnant. Spontaneous Abortion Treatment of a spontaneous abortion, any trimester, may be considered medically necessary. II. PRODUCT VARIATIONS Some groups have non-standard abortion benefits and elective abortions are not covered or are covered only when the life of the mother would be endangered if the fetus were carried to term, or if the pregnancy is a result of rape or incest. This exclusion may extend to both surgical and medical abortions, including abortions using mifepristone (i.e., the abortion pill, RU-486). [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] Indemnity [N] PPO [N] SpecialCare [N] HMO [N] POS [Y] FEP PPO* [Y] SeniorBlue ** [Y] SeniorBlue PPO** Page 1

2 * Elective abortions and any related services are not a covered benefit unless necessary to save the life of the mother or in the case of rape or incest. ** Elective abortions for SeniorBlue and Medicare PPO are non-covered unless the pregnancy is a result of an act of rape or incest or the mother suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place the woman in danger of death unless the abortion is performed. III. DESCRIPTION/BACKGROUND An elective (or voluntary) abortion is any act or procedure performed after conception, which results in the termination of a pregnancy other than for maternal or fetal health indications. Elective abortions may be performed through medical or surgical techniques. An elective abortion can be achieved medically through the use of mifepristone (i.e., RU- 486, the abortion pill) and generally requires three visits to the doctor. Under the approved treatment regimen, a woman first takes 600 milligrams of mifepristone (three 200-milligram pills) by mouth. These pills are dispensed directly from a doctor's office and not through a pharmacy. Two days later (on the third day following the administration of mifepristone), a woman must return to the physician's office to be examined to determine if the pregnancy has been terminated. If the physician determines that the woman is still pregnant, she will be given four hundred (400) micrograms of a second drug, Misoprostol (Cytotec), a prostaglandin that causes the uterus to contract and shed the lining. Cytotec is available at retail pharmacies. Heavy bleeding and cramping are considered normal for nine (9) to sixteen (16) days after taking mifepristone. Women will return for a follow-up visit approximately fourteen (14) days after taking mifepristone to determine whether the pregnancy has been terminated. Contraindications to use of mifepristone to terminate early pregnancy include, but are not limited to: Allergy to mifepristone or prostaglandins Bleeding disorders Chronic renal insufficiency Confirmed or suspected ectopic (tubal) pregnancy Current or historical use of anticoagulant therapy Recent or current long-term treatment with corticosteroids The presence of an Intrauterine Device (IUD) Page 2

3 IV. DEFINITIONS ABORTION is the termination of pregnancy by any means before the fetus is sufficiently developed to survive. In the United States, this may mean a fetus before 20 weeks gestational age or which weighs less than 500 grams. However, this definition may vary by state. ELECTIVE OR VOLUNTARY ABORTION is the termination of a pregnancy before viability and at the request of the female patient but not for reasons of impaired maternal or fetal disease. RU-486 (MIFEPRISTONE) is a Food and Drug Administration (FDA) approved pill used for the termination of early pregnancy, defined as forty-nine (49) days or less, counting from the beginning of the last menstrual period. SEPTIC ABORTION is an abortion in which there is an infection of the products of conception. SPONTANEOUS ABORTION is an abortion occurring without apparent cause, also referred to as miscarriage. These are divided into 5 sub-categories: threatened, inevitable, missed, incomplete, and recurrent abortion. V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. Page 3

4 VII. REFERENCES Centers for Medicare and Medicaid Services (CMS) National Coverage Decision (NCD) 140.1: Abortion. Effective 06/19/06. CMS [Website]: %2E1%3A2%3AAbortion. Accessed January 18, Taber's Cyclopedic Medical Dictionary, 19 th edition United States Department of Health and Human Services HHS News September 28, 2000, "FDA Approves Mifepristone for the Termination of Early Pregnancy." Williams Obstetrics, 20 th Edition. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code Description S0190 S0191 S0199 S2260 S2265 S2266 S2267 MITEPRISTONE, ORAL, 200 MG MISOPROSTOL, ORAL, 200 MCG MED INDUCED AB ORAL INGESTION MED W/SRVC & SPL INDUCED ABORTION, 17 TO 24 WEEKS INDUCED ABORTION, 25 TO 28 WEEKS INDUCED ABORTION, 29 TO 31 WEEKS INDUCED ABORTION, 32 WEEKS OR GREATER Page 4

5 ICD-9-CM Diagnosis Code* Description MALIGNANT NEOPLASM OF FEMALE BREAST MALIGNANT NEOPLASM OF CERVIX UTERI MALIGNANT NEOPLASM OF OVARY AND OTHER UTERINE ADNEXA 193. MALIGNANT NEOPLASM OF THYROID GLAND SECONDARY DIABETES MELLITUS DIABETES MELLITUS CYSTIC FIBROSIS DISORDERS INVOLVING THE IMMUNE MECHANISM SICKLE-CELL DISEASE AUTOIMMUNE HEMOLYTIC ANEMIAS COAGULATION DEFECTS DISEASES OF MITRAL VALVE HYPERTENSIVE CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE CHRONIC PULMONARY HEART DISEASE HEART FAILURE OBSTRUCTIVE CHRONIC BRONCHITIS ASTHMA 496 CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED LUNG INVOLVEMENT IN CONDITIONS CLASSIFIED ELSEWHERE OTHER DISEASES OF LUNG NEPHROTIC SYNDROME CHRONIC GLOMERULONEPHRITIS NEPHRITIS AND NEPHROPATHY, NOT SPECIFIED AS ACUTE OR CHRONIC CHRONIC KIDNEY DISEASE 586. UNSPECIFIED RENAL FAILURE SPONTANEOUS ABORTION SEVERE PRE-ECLAMPSIA, ANTEPARTUM PRE-ECLAMPSIA OR ECLAMPSIA SUPERIMPOSED ON PRE-EXISTING HYPERTENSION, ANTEPARTUM COAGULATION DEFECTS COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION FETAL-MATERNAL HEMORRHAGE, ANTEPARTUM CONDITION OR COMPLICATION CHILD SEXUAL ABUSE ADULT SEXUAL ABUSE *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. Page 5

6 The following ICD-10 diagnosis codes will be effective October 1, 2013 ICD-10-CM Diagnosis Code* Description B44.81 Allergic bronchopulmonary aspergillosis B52.0 Plasmodium malariae malaria with nephropathy C Malignant neoplasm of nipple and areola, right female breast C Malignant neoplasm of nipple and areola, left female breast C Malignant neoplasm of nipple and areola, unspecified female breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast C Malignant neoplasm of central portion of unspecified female breast C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast C Malignant neoplasm of lower-inner quadrant of right female breast C Malignant neoplasm of lower-inner quadrant of left female breast C Malignant neoplasm of lower-inner quadrant of unspecified female breast C Malignant neoplasm of upper-outer quadrant of right female breast C Malignant neoplasm of upper-outer quadrant of left female breast C Malignant neoplasm of upper-outer quadrant of unspecified female breast C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of unspecified female breast C Malignant neoplasm of axillary tail of right female breast C Malignant neoplasm of axillary tail of left female breast C Malignant neoplasm of axillary tail of unspecified female breast C Malignant neoplasm of overlapping sites of right female breast C Malignant neoplasm of overlapping sites of left female breast C Malignant neoplasm of overlapping sites of unspecified female breast C Malignant neoplasm of unspecified site of right female breast C Malignant neoplasm of unspecified site of left female breast C Malignant neoplasm of unspecified site of unspecified female breast C53.0 Malignant neoplasm of endocervix C53.1 Malignant neoplasm of exocervix C53.8 Malignant neoplasm of overlapping sites of cervix uteri Page 6

7 C53.9 Malignant neoplasm of cervix uteri, unspecified C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C57.00 Malignant neoplasm of unspecified fallopian tube C57.01 Malignant neoplasm of right fallopian tube C57.02 Malignant neoplasm of left fallopian tube C57.10 Malignant neoplasm of unspecified broad ligament C57.11 Malignant neoplasm of right broad ligament C57.12 Malignant neoplasm of left broad ligament C57.3 Malignant neoplasm of parametrium C57.20 Malignant neoplasm of unspecified round ligament C57.21 Malignant neoplasm of right round ligament C57.22 Malignant neoplasm of left round ligament C57.4 Malignant neoplasm of uterine adnexa, unspecified C73 Malignant neoplasm of thyroid gland D57.00 Hb-SS disease with crisis, unspecified D57.01 Hb-SS disease with acute chest syndrome D57.02 Hb-SS disease with splenic sequestration D57.1 Sickle-cell disease without crisis D57.20 Sickle-cell/Hb-C disease without crisis D Sickle-cell/Hb-C disease with acute chest syndrome D Sickle-cell/Hb-C disease with splenic sequestration D Sickle-cell/Hb-C disease with crisis, unspecified D Sickle-cell thalassemia with acute chest syndrome D57.80 Other sickle-cell disorders without crisis D Other sickle-cell disorders with acute chest syndrome D Other sickle-cell disorders with splenic sequestration D Other sickle-cell disorders with crisis, unspecified D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D65 Disseminated intravascular coagulation [defibrination syndrome] D66 Hereditary factor VIII deficiency D67 Hereditary factor IX deficiency D68.0 Von Willebrand's disease D68.1 Hereditary factor XI deficiency Page 7

8 D68.2 Hereditary deficiency of other clotting factors D68.31 Hemorrhagic disorder due to intrinsic circulating anticoagulants D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants D68.4 Acquired coagulation factor deficiency D68.8 Other specified coagulation defects D68.9 Coagulation defect, unspecified D80.0 Hereditary hypogammaglobulinemia D80.1 Nonfamilial hypogammaglobulinemia D80.2 Selective deficiency of immunoglobulin A [IgA] D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses D80.4 Selective deficiency of immunoglobulin M [IgM] D80.5 Immunodeficiency with increased immunoglobulin M [IgM] D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia D80.7 Transient hypogammaglobulinemia of infancy D80.8 Other immunodeficiencies with predominantly antibody defects D80.9 Immunodeficiency with predominantly antibody defects, unspecified D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.4 Nezelof's syndrome D81.6 Major histocompatibility complex class I deficiency D81.7 Major histocompatibility complex class II deficiency D81.89 Other combined immunodeficiencies D81.9 Combined immunodeficiency, unspecified D82.0 Wiskott-Aldrich syndrome D82.1 Di George's syndrome D82.2 Immunodeficiency with short-limbed stature D82.3 Immunodeficiency following hereditary defective response to Epstein-Barr virus D82.4 Hyperimmunoglobulin E [IgE] syndrome D82.8 Immunodeficiency associated with other specified major defects D82.9 Immunodeficiency associated with major defect, unspecified D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8 Other common variable immunodeficiencies D83.9 Common variable immunodeficiency, unspecified Page 8

9 D84.0 Lymphocyte function antigen-1 [LFA-1] defect D84.1 Defects in the complement system D84.8 Other specified immunodeficiencies D84.9 Immunodeficiency, unspecified D89.3 Immune reconstitution syndrome D Acute graft-versus-host disease D Chronic graft-versus-host disease D Acute or chronic graft-versus-host disease D Graft-versus-host disease, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified D89.9 Disorder involving the immune mechanism, unspecified E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E E E E E E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy Page 9

10 E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E Diabetes mellitus due to underlying condition with other diabetic arthropathy E Diabetes mellitus due to underlying condition with diabetic dermatitis E Diabetes mellitus due to underlying condition with foot ulcer E Diabetes mellitus due to underlying condition with other skin ulcer E Diabetes mellitus due to underlying condition with other skin complications E Diabetes mellitus due to underlying condition with periodontal disease E Diabetes mellitus due to underlying condition with other oral complications E Diabetes mellitus due to underlying condition with hypoglycemia with coma E Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition without complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E E E E E Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Page 10

11 E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E Drug or chemical induced diabetes mellitus with other diabetic arthropathy E Drug or chemical induced diabetes mellitus with diabetic dermatitis E Drug or chemical induced diabetes mellitus with foot ulcer E Drug or chemical induced diabetes mellitus with other skin ulcer E Drug or chemical induced diabetes mellitus with other skin complications E Drug or chemical induced diabetes mellitus with periodontal disease E Drug or chemical induced diabetes mellitus with other oral complications E Drug or chemical induced diabetes mellitus with hypoglycemia with coma E Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complication E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus without complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Page 11

12 E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E Type 1 diabetes mellitus with diabetic neuropathic arthropathy E Type 1 diabetes mellitus with other diabetic arthropathy E Type 1 diabetes mellitus with diabetic dermatitis E Type 1 diabetes mellitus with foot ulcer E Type 1 diabetes mellitus with other skin ulcer E Type 1 diabetes mellitus with other skin complications E Type 1 diabetes mellitus with periodontal disease E Type 1 diabetes mellitus with other oral complications E Type 1 diabetes mellitus with hypoglycemia with coma E Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Page 12

13 E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E Type 2 diabetes mellitus with other skin complications E Type 2 diabetes mellitus with periodontal disease E Type 2 diabetes mellitus with other oral complications E Type 2 diabetes mellitus with hypoglycemia with coma E Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma Page 13

14 E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E Other specified diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with other diabetic arthropathy E Other specified diabetes mellitus with diabetic dermatitis E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer E Other specified diabetes mellitus with other skin complications E Other specified diabetes mellitus with periodontal disease E Other specified diabetes mellitus with other oral complications E Other specified diabetes mellitus with hypoglycemia with coma E Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication Page 14

15 E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E84.9 Cystic fibrosis, unspecified I05.0 Rheumatic mitral stenosis I05.1 Rheumatic mitral insufficiency I05.2 Rheumatic mitral stenosis with insufficiency I05.8 Other rheumatic mitral valve diseases I05.9 Rheumatic mitral valve disease, unspecified I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 I13.0 I13.10 I13.11 I13.2 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I27.0 Primary pulmonary hypertension I27.1 Kyphoscoliotic heart disease I27.2 Other secondary pulmonary hypertension I27.81 Cor pulmonale (chronic) I27.82 Chronic pulmonary embolism I27.89 Other specified pulmonary heart diseases I27.9 Pulmonary heart disease, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure Page 15

16 I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified J17 Pneumonia in diseases classified elsewhere J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J Unspecified asthma with (acute) exacerbation J Unspecified asthma with status asthmaticus J Unspecified asthma, uncomplicated J Exercise induced bronchospasm J Cough variant asthma J Other asthma J80 Acute respiratory distress syndrome J81.0 Acute pulmonary edema J82 Pulmonary eosinophilia, not elsewhere classified J95.1 Acute pulmonary insufficiency following thoracic surgery J95.2 Acute pulmonary insufficiency following nonthoracic surgery J95.3 Chronic pulmonary insufficiency following surgery J95.82 Postprocedural respiratory failure J95.84 Transfusion-related acute lung injury (TRALI) J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia Page 16

17 J96.02 Acute respiratory failure with hypercapnia J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.11 Chronic respiratory failure with hypoxia J96.12 Chronic respiratory failure with hypercapnia J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.21 Acute and chronic respiratory failure with hypoxia J96.22 Acute and chronic respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia J98.11 Atelectasis J98.19 Other pulmonary collapse J98.2 Interstitial emphysema J98.3 Compensatory emphysema J98.4 Other disorders of lung J99 Respiratory disorders in diseases classified elsewhere M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.11 Other dermatopolymyositis with respiratory involvement M33.21 Polymyositis with respiratory involvement M33.91 Dermatopolymyositis, unspecified with respiratory involvement M34.81 Systemic sclerosis with lung involvement M35.02 Sicca syndrome with lung involvement M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.9 Systemic involvement of connective tissue, unspecified N02.1 Recurrent and persistent hematuria with focal and segmental glomerular lesions N02.2 Recurrent and persistent hematuria with diffuse membranous glomerulonephritis N02.3 Recurrent and persistent hematuria with diffuse mesangial proliferative glomerulonephritis N02.4 Recurrent and persistent hematuria with diffuse endocapillary proliferative glomerulonephritis N02.5 Recurrent and persistent hematuria with diffuse mesangiocapillary glomerulonephritis N02.6 Recurrent and persistent hematuria with dense deposit disease N02.7 Recurrent and persistent hematuria with diffuse crescentic glomerulonephritis N02.8 Recurrent and persistent hematuria with other morphologic changes N02.9 Recurrent and persistent hematuria with unspecified morphologic changes Page 17

18 N03.0 Chronic nephritic syndrome with minor glomerular abnormality N03.1 Chronic nephritic syndrome with focal and segmental glomerular lesions N03.2 Chronic nephritic syndrome with diffuse membranous glomerulonephritis N03.3 Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis N03.4 Chronic nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis N03.5 Chronic nephritic syndrome with diffuse mesangiocapillary glomerulonephritis N03.6 Chronic nephritic syndrome with dense deposit disease N03.7 Chronic nephritic syndrome with diffuse crescentic glomerulonephritis N03.8 Chronic nephritic syndrome with other morphologic changes N03.9 Chronic nephritic syndrome with unspecified morphologic changes N04.0 Nephrotic syndrome with minor glomerular abnormality N04.1 Nephrotic syndrome with focal and segmental glomerular lesions N04.2 Nephrotic syndrome with diffuse membranous glomerulonephritis N04.3 Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis N04.4 Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis N04.5 Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis N04.6 Nephrotic syndrome with dense deposit disease N04.7 Nephrotic syndrome with diffuse crescentic glomerulonephritis N04.8 Nephrotic syndrome with other morphologic changes N04.9 Nephrotic syndrome with unspecified morphologic changes N05.0 Unspecified nephritic syndrome with minor glomerular abnormality N05.1 Unspecified nephritic syndrome with focal and segmental glomerular lesions N05.2 Unspecified nephritic syndrome with diffuse membranous glomerulonephritis N05.3 Unspecified nephritic syndrome with diffuse mesangial proliferative glomerulonephritis N05.4 Unspecified nephritic syndrome with diffuse endocapillary proliferative glomerulonephritis N05.5 Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis N05.6 Unspecified nephritic syndrome with dense deposit disease N05.7 Unspecified nephritic syndrome with diffuse crescentic glomerulonephritis N05.8 Unspecified nephritic syndrome with other morphologic changes N05.9 Unspecified nephritic syndrome with unspecified morphologic changes N06.0 Isolated proteinuria with minor glomerular abnormality N06.1 Isolated proteinuria with focal and segmental glomerular lesions N06.2 Isolated proteinuria with diffuse membranous glomerulonephritis N06.3 Isolated proteinuria with diffuse mesangial proliferative glomerulonephritis N06.4 Isolated proteinuria with diffuse endocapillary proliferative glomerulonephritis N06.5 Isolated proteinuria with diffuse mesangiocapillary glomerulonephritis Page 18

19 N06.6 Isolated proteinuria with dense deposit disease N06.7 Isolated proteinuria with diffuse crescentic glomerulonephritis N06.8 Isolated proteinuria with other morphologic lesion N06.9 Isolated proteinuria with unspecified morphologic lesion N07.0 Hereditary nephropathy, not elsewhere classified with minor glomerular abnormality N07.1 Hereditary nephropathy, not elsewhere classified with focal and segmental glomerular lesions N07.2 Hereditary nephropathy, not elsewhere classified with diffuse membranous glomerulonephritis N07.3 Hereditary nephropathy, not elsewhere classified with diffuse mesangial proliferative glomerulonephritis N07.4 Hereditary nephropathy, not elsewhere classified with diffuse endocapillary proliferative glomerulonephritis N07.5 Hereditary nephropathy, not elsewhere classified with diffuse mesangiocapillary glomerulonephritis N07.6 Hereditary nephropathy, not elsewhere classified with dense deposit disease N07.7 Hereditary nephropathy, not elsewhere classified with diffuse crescentic glomerulonephritis N07.8 Hereditary nephropathy, not elsewhere classified with other morphologic lesions N07.9 Hereditary nephropathy, not elsewhere classified with unspecified morphologic lesions N08 Glomerular disorders in diseases classified elsewhere N14.0 Analgesic nephropathy N14.1 Nephropathy induced by other drugs, medicaments and biological substances N14.2 Nephropathy induced by unspecified drug, medicament or biological substance N14.3 Nephropathy induced by heavy metals N14.4 Toxic nephropathy, not elsewhere classified N15.0 Balkan nephropathy N15.8 Other specified renal tubulo-interstitial diseases N15.9 Renal tubulo-interstitial disease, unspecified N16 Renal tubulo-interstitial disorders in diseases classified elsewhere N17.1 Acute kidney failure with acute cortical necrosis N17.2 Acute kidney failure with medullary necrosis N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified N19 Unspecified kidney failure O03.0 Genital tract and pelvic infection following incomplete spontaneous abortion O03.1 Delayed or excessive hemorrhage following incomplete spontaneous abortion Page 19

20 O03.2 Embolism following incomplete spontaneous abortion O03.35 Other venous complications following incomplete spontaneous abortion O03.36 Cardiac arrest following incomplete spontaneous abortion O03.38 Urinary tract infection following incomplete spontaneous abortion O03.39 Incomplete spontaneous abortion with other complications O03.5 Genital tract and pelvic infection following complete or unspecified spontaneous abortion O03.6 Delayed or excessive hemorrhage following complete or unspecified spontaneous abortion O03.30 Unspecified complication following incomplete spontaneous abortion O03.31 Shock following incomplete spontaneous abortion O03.32 Renal failure following incomplete spontaneous abortion O03.33 Metabolic disorder following incomplete spontaneous abortion O03.34 Damage to pelvic organs following incomplete spontaneous abortion O03.4 Incomplete spontaneous abortion without complication O03.7 Embolism following complete or unspecified spontaneous abortion O03.80 Unspecified complication following complete or unspecified spontaneous abortion O03.81 Shock following complete or unspecified spontaneous abortion O03.82 Renal failure following complete or unspecified spontaneous abortion O03.83 Metabolic disorder following complete or unspecified spontaneous abortion O03.84 Damage to pelvic organs following complete or unspecified spontaneous abortion O03.85 Other venous complications following complete or unspecified spontaneous abortion O03.86 Cardiac arrest following complete or unspecified spontaneous abortion O03.88 Urinary tract infection following complete or unspecified spontaneous abortion O03.89 Complete or unspecified spontaneous abortion with other complications O03.9 Complete or unspecified spontaneous abortion without complication O11.1 Pre-existing hypertension with pre-eclampsia, first trimester O11.2 Pre-existing hypertension with pre-eclampsia, second trimester O11.3 Pre-existing hypertension with pre-eclampsia, third trimester O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester O14.10 Severe pre-eclampsia, unspecified trimester O14.12 Severe pre-eclampsia, second trimester O14.13 Severe pre-eclampsia, third trimester O14.22 HELLP syndrome (HELLP), second trimester O14.23 HELLP syndrome (HELLP), third trimester O Fetomaternal placental transfusion syndrome, first trimester O Fetomaternal placental transfusion syndrome, second trimester O Fetomaternal placental transfusion syndrome, third trimester Page 20

21 O Fetomaternal placental transfusion syndrome, unspecified trimester O Fetus-to-fetus placental transfusion syndrome, first trimester O Fetus-to-fetus placental transfusion syndrome, second trimester O Fetus-to-fetus placental transfusion syndrome, third trimester O O O O T74.21xa T74.22xa T76.21xa T76.22xa Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, first trimester Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, second trimester Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, third trimester Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, unspecified trimester Adult sexual abuse, confirmed, initial encounter Child sexual abuse, confirmed, initial encounter Adult sexual abuse, suspected, initial encounter Child sexual abuse, suspected, initial encounter *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 21

22 IX. POLICY HISTORY MP CAC 10/26/04 CAC 12/14/04 CAC 5/24/05 CAC 10/25/05 CAC 9/26/06 CAC 7/31/07 CAC 1/27/09 CAC 1/26/10 Consensus Review CAC 4/26/11 Consensus Review Policy approved for retirement effective 6/1/2011. Page 22