Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Reimbursement for Radiopharmaceutical Agents for Professional Providers

Policy #:

MA09.009t

Policy

RADIOPHARMACEUTICAL AGENTS WITH POSITRON EMISSION TOMOGRAPHY (PET) SCANS

The Company covers medically necessary radiopharmaceutical agents used in conjunction with PET scans. However, reimbursement is included in the payment for the associated procedure. Therefore, radiopharmaceutical agents used in conjunction with PET scans are not eligible for separate reimbursement. Participating providers may not bill members for this service.

Separate reimbursement may be considered for radiopharmaceutical agents granted pass-through payment status through the Centers for Medicare & Medicaid Service's Outpatient Prospective Payment System (OPPS).

RADIOPHARMACEUTICAL AGENTS FOR OTHER USES

Medically necessary radiopharmaceutical agents used in conjunction with diagnostic and therapeutic procedures other than PET scans are covered and eligible for reimbursement consideration by the Company when purchased by a professional provider and administered in an office setting.

The Company covers medically necessary radiopharmaceutical agents used in conjunction with diagnostic and therapeutic procedures other than PET scans and administered in a facility. Medically necessary radiopharmaceutical agents administered in a facility are reimbursed in accordance with the facility contract or agreement. However, radiopharmaceutical agents are not eligible for reimbursement to professional providers as payment is included in the facility reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Radiopharmaceutical agents not represented by a specific code may be billed with Not Otherwise Classified (NOC) codes A4641 (diagnostic agent) or A9699 (therapeutic agent). When reporting procedure code A4641 or A9699, the provider should report only one unit and include a description of the agent and the actual amount administered.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, radiopharmaceutical agents are covered under the medical benefits of the Company’s Medicare Advantage products.

In geographical areas with a capitated outpatient radiology program, radiopharmaceutical agents are not included in the capitated radiology program and may be eligible for fee-for-service reimbursement when all of the policy requirements are met.

Description

Radiopharmaceutical agents are radioactive chemicals or drugs that have a specific affinity for a particular body tissue or organ. They can be used in conjunction with diagnostic procedures to obtain images of structures. They can also be used in conjunction with therapeutic procedures to treat radiation-sensitive diseases.

The Centers for Medicare & Medicaid Service's (CMS) Outpatient Prospective Payment System (OPPS) typically packages the cost of ancillary services and items into the payment for the primary service. However, at times for new-to-market drugs with relatively high costs, the OPPS provides separate payment through its pass-through system. A drug can receive pass-through status typically for a period of not less than 2 years but not exceeding 3 years.

References

Centers for Medicare & Medicaid Services (CMS). Billing and Coding Guidelines for Radiopharmaceutical Agents (RAD-026). 90.2 Drugs, Biologicals, and Radiopharmaceuticals. Coding Radiopharmaceuticals. [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/lcd_attachments/31361_1/L31361_RAD026_CBG_060111.pdf. Accessed April 9, 2021.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 17: Drugs and Biologicals. 90.2: Drugs, Biologicals, and Radiopharmaceuticals. [CMS Web site]. 08/08/20. Available at: https://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed April 9, 2021.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology services and other diagnostic procedures. 110.3: Payment for radiopharmaceuticals. [CMS Web site]. 03/27/19. Available at: https://www.cms.gov/manuals/downloads/clm104c13.pdf. Accessed April 9, 2021.

The Medicare Payment Advisory Commission (MedPAC). Separately payable drugs in the hospital outpatient prospective payment system. Report to Congress: CMS and HC Deliv Sys. June 2020:163-164. Also available on the MedPAC Web site at: jun20_ch6_reporttocongress_sec.pdf (medpac.gov). Accessed April 19, 2021.

Novitas Solutions, Inc. Reimbursement Guidelines for Diagnostic Radiopharmaceutical Procedure Codes. 06/19/20. Available at:
Provider Specialty: Reimbursement Guidelines for Radiopharmaceutical Procedure Codes (novitas-solutions.com). Accessed April 19, 2021.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

RADIOPHARMACEUTICAL AGENTS USED WITH POSITRON EMISSION TOMOGRAPHY (PET) SCANS

The following radiopharmaceuticals should only be reported when used with PET scans.

ELIGIBLE

A9590	Iodine I-131, iobenguane, 1 mCi
A9591	Fluoroestradiol f 18, diagnostic, 1 millicurie
A9592	Copper cu-64, dotatate, diagnostic, 1 millicurie
A9593	Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie
A9594	Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie
A9595	Piflufolastat f-18, diagnostic, 1 millicurie
A9596	Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie
A9602	Fluorodopa f-18, diagnostic, per millicurie
A9608	Flotufolastat f 18, diagnostic, 1 millicurie
A9800	Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

A9515	Choline C-11, diagnostic, per study dose up to 20 mCi
A9526	Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 mCi
A9552	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi
A9555	Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
A9580	Sodium fluoride F-18, diagnostic, per study dose, up to 30 mCi
A9586	Florbetapir F18, diagnostic, per study dose, up to 10 mCi
A9587	Gallium Ga-68, dotatate, diagnostic, 0.1 mCi
A9588	Fluciclovine F-18, diagnostic, 1 mCi
A9597	Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified
A9598	Positron emission tomography radiopharmaceutical, diagnostic, for nontumor identification, not otherwise classified
A9601	Flortaucipir f 18 injection, diagnostic, 1 millicurie
A9609	Fludeoxyglucose f18 up to 15 millicuries
Q9982	Flutemetamol F18, diagnostic, per study dose, up to 5 mCi
Q9983	Florbetaben F18, diagnostic, per study dose, up to 8.1 mCi

RADIOPHARMACEUTICAL AGENTS USED WITH PROCEDURES OTHER THAN POSITRON EMISSION TOMOGRAPHY (PET) SCANS

A4642	Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 mCi
A9500	Technetium Tc-99m sestamibi, diagnostic, per study dose
A9501	Technetium Tc-99m teboroxime, diagnostic, per study dose
A9502	Technetium Tc-99m tetrofosmin, diagnostic, per study dose
A9503	Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 mCi
A9504	Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 mCi
A9505	Thallium Tl-201 thallous chloride, diagnostic, per mCi
A9507	Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries
A9508	Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 mCi
A9509	Iodine I-123 sodium iodide, diagnostic, per mCi
A9510	Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 mCi
A9512	Technetium Tc-99m pertechnetate, diagnostic, per mCi
A9516	Iodine I-123 sodium iodide, diagnostic, per 100 mcCi, up to 999 mcCi
A9517	Iodine I-131 sodium iodide capsule(s), therapeutic, per mCi
A9520	Technetium Tc-99m, tilmanocept, diagnostic, up to 0.5 mCi
A9521	Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 mCi
A9524	Iodine I-131 iodinated serum albumin, diagnostic, per 5 mcCi
A9527	Iodine I-125, sodium iodide solution, therapeutic, per mCi
A9528	Iodine I-131 sodium iodide capsule(s), diagnostic, per mCi
A9529	Iodine I-131 sodium iodide solution, diagnostic, per mCi
A9530	Iodine I-131 sodium iodide solution, therapeutic, per mCi
A9531	Iodine I-131 sodium iodide, diagnostic, per mcCi (up to 100 mcCi)
A9532	Iodine I-125 serum albumin, diagnostic, per 5 mcCi
A9536	Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 mCi
A9537	Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 mCi
A9538	Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 mCi
A9539	Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 mCi
A9540	Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 mCi
A9541	Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 mCi
A9542	Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 mCi
A9543	Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 mCi
A9546	Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 mcCi
A9547	Indium In-111 oxyquinoline, diagnostic, per 0.5 mCi
A9548	Indium In-111 pentetate, diagnostic, per 0.5 mCi
A9550	Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 mCi
A9551	Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 mCi
A9553	Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 mcCi
A9554	Iodine I-125 sodium iothalamate, diagnostic, per study dose, up to 10 mcCi
A9555	Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
A9556	Gallium Ga-67 citrate, diagnostic, per mCi
A9557	Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 mCi
A9558	Xenon Xe-133 gas, diagnostic, per 10 mCi
A9559	Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 mcCi
A9560	Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 mCi
A9561	Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 mCi
A9562	Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 mCi
A9563	Sodium phosphate P-32, therapeutic, per mCi
A9564	Chromic phosphate P-32 suspension, therapeutic, per mCi
A9566	Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 mCi
A9567	Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 mCi
A9568	Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 mCi
A9569	Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose
A9570	Indium In-111 labeled autologous white blood cells, diagnostic, per study dose
A9571	Indium In-111 labeled autologous platelets, diagnostic, per study dose
A9572	Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 mCi
A9582	Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 mCi
A9584	Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 mCi
A9600	Strontium Sr-89 chloride, therapeutic, per mCi
A9603	Injection, pafolacianine, 0.1 mg
A9604	Samarium Sm-153 lexidronam, therapeutic, per treatment dose, up to 150 mCi
A9606	Radium RA-223 dichloride, therapeutic, per mcCi
A9607	Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie
Q9969	Tc-99m from nonhighly enriched uranium source, full cost recovery add-on, per study dose

THE FOLLOWING NOT OTHERWISE CLASSIFIED (NOC) CODES SHOULD BE USED TO REPORT THE SUPPLY OF RADIOPHARMACEUTICAL AGENTS WHEN NOT LISTED ABOVE

A4641	Radiopharmaceutical, diagnostic, not otherwise classified
A9699	Radiopharmaceutical, therapeutic, not otherwise classifed

Revenue Code Number(s)

0343	Diagnostic Radiopharmaceuticals
0344	Therapeutic Radiopharmaceuticals

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA09.009t:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024.

HCPCS code A9608 and A9609 have been added to the policy.

Revisions From MA09.009s:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
10/01/2023	This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2023. HCPCS code A9603 has been added to the policy.

Revisions From MA09.009r:

12/19/2022

This version of the policy will become effective 12/19/2022. The policy has been updated to clarify the reimbursement position for procedure code A9607.

Revisions From MA09.009q:

10/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2022.

HCPCS codes A9602, A9607, and A9800 have been added to the policy.

Revisions From MA09.009p:

07/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2022.

HCPCS codes A9596 and A9601 have been added to the policy.

Revisions From MA09.009o:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.

HCPCS code A9595 have been added to the policy.

The Company's reimbursement position for following radiopharmaceutical agents used with PET Scans have been have changed from Not Eligible for Separate Reimbursement to eligible:

A9593 and A9594

Revisions From MA09.009n:

08/16/2021

This version of the policy will become effective 08/16/2021. This policy has been updated to address the Company's reimbursement criteria for radiopharmaceutical agents granted payment on the Center for Medicaid and Medicare's Outpatient Prospective Payment System.

The following criteria has been added to the policy:

Separate reimbursement may be considered for radiopharmaceutical agents granted pass-through payment status through the Centers for Medicare and Medicaid Service's Outpatient Prospective Payment System (OPPS).

HCPCs code A9590 (eligible) has been added to the policy.

Revisions From MA09.009m:

07/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

Procedure codes A9593 and A9594 have been added to the policy.

Revisions From MA09.009l:

04/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2021.

Procedure code A9592 was added to the policy.

Revisions From MA09.009k:

01/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

Procedure code A9591 was added to the policy.

Revisions From MA09.009j:

12/02/2019

This version of the policy will become effective 12/02/2019. The policy communicates the Company’s continuing position on Reimbursement for Radiopharmaceutical Agents for Professional Providers. Language was made more concise. The following procedure code was added to the section Radiopharmaceutical Agents Used With Procedures Other Than Positron Emission Tomography (PET) Scans:

A9584 Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 mCi

Revisions From MA09.009i:

09/24/2018

This version of the policy will become effective 09/24/2018.

This policy was updated to communicate the Company's continuing coverage position. Policy language was revised to clarify Professional Provider and Facility reimbursement.

Revisions From MA09.009h:

01/01/2018

This policy has been identified for the CPT code update.

The following CPT code has been deleted from this policy, effective 12/31/2017: A9599

Revisions From MA09.009g:

01/01/2017

This policy has been identified for the CPT code update.

The following CPT codes have been added to this policy, effective 01/01/2017, policy under the DIAGNOSTIC RADIOPHARMACEUTICALS USED WITH PET category as this service is only done with PET, and therefore not eligible for reimbursement.:

A9515, A9587, A9588, A9597, A9598

The following CPT codes has been deleted from this policy, effective 12/31/2016:

A9544, A9545, C9461

The following CPT codes have been revised in this policy, effective 01/01/2017:

FROM:

A9599 radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose

TO:

A9599 Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose, not otherwise specified

Revisions From MA09.009f:

01/01/2017

HCPCS code A9584 is being removed from this policy and added to policy #12.01.01ai: Experimental/Investigational Services, effective 01/01/2017.

Revisions From MA09.009e:

07/01/2016

This policy has been identified for the HCPCS/CPT code update.

The following HCPCS codes have been removed from this policy, effective 6/30/2016:

C9458: Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries
C9459: Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries

The following HCPCS codes have been added to this policy, effective 7/1/2016:

Q9982: Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
Q9983: Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries

Revisions From MA09.009d:

04/01/2016

This policy has been identified for the HCPCS code update, effective 04/01/2016.

The following HCPCS codes have been added to this policy:
C9461: Choline C 11, diagnostic, per study dose

Revisions From MA09.009c:

01/01/2016

This policy has been identified for the HCPCS code update, effective 01/01/2016.

The following HCPCS codes have been added to this policy:
C9458: Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries
C9459: Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries

Revisions From MA09.009b:

12/01/2015

Policy # MA09.009b has been identified for a coding change, effective 12/01/2015.

(HCPCS) Service code A9582 (Iodine I-123 Iobenguane, diagnostic, per study dose, up to 15 millicuries) was incorrectly applied as a PET radiopharmaceutical code. The policy was updated to remove service code A9582 from the title: DIAGNOSTIC RADIOPHARMACEUTICALS USED WITH PET and add to the title: DIAGNOSTIC RADIOPHARMACEUTICALS USED FOR NUCLEAR IMAGING PROCEDURES OTHER THAN POSITRON EMISSION TOMOGRAPHY (PET) SCANS.

Revisions From MA09.009a:

03/18/2015

The following HCPCS code has been added to the policy under the following categories:

THERAPEUTIC RADIOPHARMACEUTICALS

A9606: Radium ra-223 dichloride, therapeutic, per microcurie

Revisions From MA09.009:

01/01/2015

This is a new policy.

Version Effective Date:

1/2/2024

Version Issued Date:

1/9/2024

Version Reissued Date: