In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 17: Drugs and Biologicals. 90.2: Drugs, Biologicals, and Radiopharmaceuticals. [CMS Web site]. 02/08/19. Available at: https://www.cms.gov/manuals/downloads/clm104c17.pdf. Accessed September 12, 2019.
Centers for Medicare and 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 September 12, 2019.
Company Benefit Contracts.
Novitas Solutions, Inc. Reimbursement Guidelines for Diagnostic Radiopharmaceutical Procedure Codes. 08/27/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00024985. Accessed October 15, 2019.
The following radiopharmaceuticals should only be reported when used with PET scans. They are not eligible for separate reimbursement.
Policy: 08.00.08j:Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
Policy: 09.00.56j:Radiation Therapy Services (AmeriHealth)