Notification

Proton Beam Radiation Therapy


Notification Issue Date: 05/31/2019



Policy Attachment



Attachment to Policy # 09.00.49l


Attachment:A

Policy #:09.00.49l

Description:ICD-10 Diagnosis Codes

Title:Proton Beam Radiation Therapy


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

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



MEDICALLY NECESSARY

C22.0 Liver cell carcinoma

C22.1 Intrahepatic bile duct carcinoma

C22.2 Hepatoblastoma

C22.3 Angiosarcoma of liver

C22.4 Other sarcomas of liver

C22.7 Other specified carcinomas of liver

C22.8 Malignant neoplasm of liver, primary, unspecified as to type

C22.9 Malignant neoplasm of liver, not specified as primary or secondary

C41.0 Malignant neoplasm of bones of skull and face

C41.9 Malignant neoplasm of bone and articular cartilage, unspecified

C62.00 Malignant neoplasm of unspecified undescended testis

C62.01 Malignant neoplasm of undescended right testis

C62.02 Malignant neoplasm of undescended left testis

C62.10 Malignant neoplasm of unspecified descended testis

C62.11 Malignant neoplasm of descended right testis

C62.12 Malignant neoplasm of descended left testis

C62.90 Malignant neoplasm of unspecified testis, unspecified whether descended or undescended

C62.91 Malignant neoplasm of right testis, unspecified whether descended or undescended

C62.92 Malignant neoplasm of left testis, unspecified whether descended or undescended

C63.7 Malignant neoplasm of other specified male genital organs

C63.8 Malignant neoplasm of overlapping sites of male genital organs

C69.30 Malignant neoplasm of unspecified choroid

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

C69.40 Malignant neoplasm of unspecified ciliary body

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

C69.90 Malignant neoplasm of unspecified site of unspecified eye

C69.91 Malignant neoplasm of unspecified site of right eye

C69.92 Malignant neoplasm of unspecified site of left eye


NOT MEDICALLY NECESSARY

C01 Malignant neoplasm of base of tongue

C02.0 Malignant neoplasm of dorsal surface of tongue

C02.1 Malignant neoplasm of border of tongue

C02.2 Malignant neoplasm of ventral surface of tongue

C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C02.4 Malignant neoplasm of lingual tonsil

C02.8 Malignant neoplasm of overlapping sites of tongue

C02.9 Malignant neoplasm of tongue, unspecified

C03.0 Malignant neoplasm of upper gum

C03.1 Malignant neoplasm of lower gum

C03.9 Malignant neoplasm of gum, unspecified

C04.0 Malignant neoplasm of anterior floor of mouth

C04.1 Malignant neoplasm of lateral floor of mouth

C04.8 Malignant neoplasm of overlapping sites of floor of mouth

C04.9 Malignant neoplasm of floor of mouth, unspecified

C05.0 Malignant neoplasm of hard palate

C05.1 Malignant neoplasm of soft palate

C05.2 Malignant neoplasm of uvula

C05.8 Malignant neoplasm of overlapping sites of palate

C05.9 Malignant neoplasm of palate, unspecified

C06.0 Malignant neoplasm of cheek mucosa

C06.1 Malignant neoplasm of vestibule of mouth

C06.2 Malignant neoplasm of retromolar area

C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth

C06.89 Malignant neoplasm of overlapping sites of other parts of mouth

C06.9 Malignant neoplasm of mouth, unspecified

C07 Malignant neoplasm of parotid gland

C08.0 Malignant neoplasm of submandibular gland

C08.1 Malignant neoplasm of sublingual gland

C08.9 Malignant neoplasm of major salivary gland, unspecified

C09.0 Malignant neoplasm of tonsillar fossa

C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)

C09.8 Malignant neoplasm of overlapping sites of tonsil

C09.9 Malignant neoplasm of tonsil, unspecified

C10.0 Malignant neoplasm of vallecula

C10.1 Malignant neoplasm of anterior surface of epiglottis

C10.2 Malignant neoplasm of lateral wall of oropharynx

C10.3 Malignant neoplasm of posterior wall of oropharynx

C10.4 Malignant neoplasm of branchial cleft

C10.8 Malignant neoplasm of overlapping sites of oropharynx

C10.9 Malignant neoplasm of oropharynx, unspecified

C11.0 Malignant neoplasm of superior wall of nasopharynx

C11.1 Malignant neoplasm of posterior wall of nasopharynx

C11.2 Malignant neoplasm of lateral wall of nasopharynx

C11.3 Malignant neoplasm of anterior wall of nasopharynx

C11.8 Malignant neoplasm of overlapping sites of nasopharynx

C11.9 Malignant neoplasm of nasopharynx, unspecified

C12 Malignant neoplasm of pyriform sinus

C13.0 Malignant neoplasm of postcricoid region

C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect

C13.2 Malignant neoplasm of posterior wall of hypopharynx

C13.8 Malignant neoplasm of overlapping sites of hypopharynx

C13.9 Malignant neoplasm of hypopharynx, unspecified

C14.0 Malignant neoplasm of pharynx, unspecified

C14.2 Malignant neoplasm of Waldeyer's ring

C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C15.3 Malignant neoplasm of upper third of esophagus

C15.4 Malignant neoplasm of middle third of esophagus

C15.5 Malignant neoplasm of lower third of esophagus

C15.8 Malignant neoplasm of overlapping sites of esophagus

C15.9 Malignant neoplasm of esophagus, unspecified

C25.0 Malignant neoplasm of head of pancreas

C25.1 Malignant neoplasm of body of pancreas

C25.2 Malignant neoplasm of tail of pancreas

C25.3 Malignant neoplasm of pancreatic duct

C25.4 Malignant neoplasm of endocrine pancreas

C25.7 Malignant neoplasm of other parts of pancreas

C25.8 Malignant neoplasm of overlapping sites of pancreas

C25.9 Malignant neoplasm of pancreas, unspecified

C30.0 Malignant neoplasm of nasal cavity

C30.1 Malignant neoplasm of middle ear

C31.0 Malignant neoplasm of maxillary sinus

C31.1 Malignant neoplasm of ethmoidal sinus

C31.2 Malignant neoplasm of frontal sinus

C31.3 Malignant neoplasm of sphenoid sinus

C31.8 Malignant neoplasm of overlapping sites of accessory sinuses

C31.9 Malignant neoplasm of accessory sinus, unspecified

C32.0 Malignant neoplasm of glottis

C32.1 Malignant neoplasm of supraglottis

C32.2 Malignant neoplasm of subglottis

C32.3 Malignant neoplasm of laryngeal cartilage

C32.8 Malignant neoplasm of overlapping sites of larynx

C32.9 Malignant neoplasm of larynx, unspecified

C33 Malignant neoplasm of trachea

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C47.0 Malignant neoplasm of peripheral nerves of head, face and neck

C48.0 Malignant neoplasm of retroperitoneum

C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck

C50.011 Malignant neoplasm of nipple and areola, right female breast

C50.012 Malignant neoplasm of nipple and areola, left female breast

C50.019 Malignant neoplasm of nipple and areola, unspecified female breast

C50.021 Malignant neoplasm of nipple and areola, right male breast

C50.022 Malignant neoplasm of nipple and areola, left male breast

C50.029 Malignant neoplasm of nipple and areola, unspecified male breast

C50.111 Malignant neoplasm of central portion of right female breast

C50.112 Malignant neoplasm of central portion of left female breast

C50.119 Malignant neoplasm of central portion of unspecified female breast

C50.121 Malignant neoplasm of central portion of right male breast

C50.122 Malignant neoplasm of central portion of left male breast

C50.129 Malignant neoplasm of central portion of unspecified male breast

C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast

C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast

C50.221 Malignant neoplasm of upper-inner quadrant of right male breast

C50.222 Malignant neoplasm of upper-inner quadrant of left male breast

C50.229 Malignant neoplasm of upper-inner quadrant of unspecified male breast

C50.311 Malignant neoplasm of lower-inner quadrant of right female breast

C50.312 Malignant neoplasm of lower-inner quadrant of left female breast

C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast

C50.321 Malignant neoplasm of lower-inner quadrant of right male breast

C50.322 Malignant neoplasm of lower-inner quadrant of left male breast

C50.329 Malignant neoplasm of lower-inner quadrant of unspecified male breast

C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

C50.412 Malignant neoplasm of upper-outer quadrant of left female breast

C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast

C50.421 Malignant neoplasm of upper-outer quadrant of right male breast

C50.422 Malignant neoplasm of upper-outer quadrant of left male breast

C50.429 Malignant neoplasm of upper-outer quadrant of unspecified male breast

C50.511 Malignant neoplasm of lower-outer quadrant of right female breast

C50.512 Malignant neoplasm of lower-outer quadrant of left female breast

C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast

C50.521 Malignant neoplasm of lower-outer quadrant of right male breast

C50.522 Malignant neoplasm of lower-outer quadrant of left male breast

C50.529 Malignant neoplasm of lower-outer quadrant of unspecified male breast

C50.611 Malignant neoplasm of axillary tail of right female breast

C50.612 Malignant neoplasm of axillary tail of left female breast

C50.619 Malignant neoplasm of axillary tail of unspecified female breast

C50.621 Malignant neoplasm of axillary tail of right male breast

C50.622 Malignant neoplasm of axillary tail of left male breast

C50.629 Malignant neoplasm of axillary tail of unspecified male breast

C50.811 Malignant neoplasm of overlapping sites of right female breast

C50.812 Malignant neoplasm of overlapping sites of left female breast

C50.819 Malignant neoplasm of overlapping sites of unspecified female breast

C50.911 Malignant neoplasm of unspecified site of right female breast

C50.912 Malignant neoplasm of unspecified site of left female breast

C50.919 Malignant neoplasm of unspecified site of unspecified female breast

C61 Malignant neoplasm of prostate

C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles

C71.1 Malignant neoplasm of frontal lobe

C71.2 Malignant neoplasm of temporal lobe

C71.3 Malignant neoplasm of parietal lobe

C71.4 Malignant neoplasm of occipital lobe

C71.5 Malignant neoplasm of cerebral ventricle

C71.6 Malignant neoplasm of cerebellum

C71.7 Malignant neoplasm of brain stem

C71.8 Malignant neoplasm of overlapping sites of brain

C71.9 Malignant neoplasm of brain, unspecified

C76.0 Malignant neoplasm of head, face and neck

C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck

C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site

C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.02 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes

C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes

C81.04 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.05 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.06 Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes

C81.07 Nodular lymphocyte predominant Hodgkin lymphoma, spleen

C81.08 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites

C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites

C81.10 Nodular sclerosis Hodgkin lymphoma, unspecified site

C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes

C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes

C81.14 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.15 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes

C81.17 Nodular sclerosis Hodgkin lymphoma, spleen

C81.18 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple site

C81.19 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites

C81.20 Mixed cellularity Hodgkin lymphoma, unspecified site

C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes

C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes

C81.24 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.25 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes

C81.27 Mixed cellularity Hodgkin lymphoma, spleen

C81.28 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites

C81.29 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites

C81.30 Lymphocyte depleted Hodgkin lymphoma, unspecified site

C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes

C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes

C81.34 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.35 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes

C81.37 Lymphocyte depleted Hodgkin lymphoma, spleen

C81.38 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites

C81.39 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites

C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site

C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes

C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes

C81.44 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.45 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes

C81.47 Lymphocyte-rich Hodgkin lymphoma, spleen

C81.48 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites

C81.49 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites

C81.70 Other Hodgkin lymphoma, unspecified site

C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes

C81.73 Other Hodgkin lymphoma, intra-abdominal lymph nodes

C81.74 Other Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.75 Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.76 Other Hodgkin lymphoma, intrapelvic lymph nodes

C81.77 Other Hodgkin lymphoma, spleen

C81.78 Other Hodgkin lymphoma, lymph nodes of multiple sites

C81.79 Other Hodgkin lymphoma, extranodal and solid organ sites

C85.10 Unspecified B-cell lymphoma, unspecified site

C85.11 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck

C85.12 Unspecified B-cell lymphoma, intrathoracic lymph nodes

C85.13 Unspecified B-cell lymphoma, intra-abdominal lymph nodes

C85.14 Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb

C85.15 Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb

C85.16 Unspecified B-cell lymphoma, intrapelvic lymph nodes

C85.17 Unspecified B-cell lymphoma, spleen

C85.18 Unspecified B-cell lymphoma, lymph nodes of multiple sites

C85.19 Unspecified B-cell lymphoma, extranodal and solid organ sites

C85.20 Mediastinal (thymic) large B-cell lymphoma, unspecified site

C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck

C85.22 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes

C85.23 Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes

C85.24 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb

C85.25 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb

C85.26 Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes

C85.27 Mediastinal (thymic) large B-cell lymphoma, spleen

C85.28 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites

C85.29 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites

C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site

C85.81 Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck

C85.82 Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes

C85.83 Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes

C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb

C85.85 Other specified types of non-Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C85.86 Other specified types of non-Hodgkin lymphoma, intrapelvic lymph nodes

C85.87 Other specified types of non-Hodgkin lymphoma, spleen

C85.88 Other specified types of non-Hodgkin lymphoma, lymph nodes of multiple sites

C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites

C81.90 Hodgkin lymphoma, unspecified, unspecified site

C81.91 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck

C81.92 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes

C81.93 Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes

C81.94 Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb

C81.95 Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb

C81.96 Hodgkin lymphoma, unspecified, intrapelvic lymph nodes

C81.97 Hodgkin lymphoma, unspecified, spleen

C81.98 Hodgkin lymphoma, unspecified, lymph nodes of multiple sites

C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites

C85.90 Non-Hodgkin lymphoma, unspecified, unspecified site

C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck

C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes

C85.93 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes

C85.94 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb

C85.94 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb

C85.95 Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb

C85.96 Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes

C85.97 Non-Hodgkin lymphoma, unspecified, spleen

C85.98 Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites

C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites

D07.5 Carcinoma in situ of prostate

Version Effective Date: 07/01/2019
Version Issued Date: 07/01/2019
Version Reissued Date: N/A



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