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Elizabeth M. Whitehorn, Director

Expensive Drugs and Devices Listing for Hospitals and ASTCs

Codes Effective 11/01/09

Cardioverter/Defibrillators

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1721 Cardioverter-defibrillator, dual chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode leads(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
C1722 Cardioverter-defibrillator, single chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode leads(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode leads(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator

Cochlear Devices

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
L8614 Cochlear device, includes all internal and external components No 69930 Cochlear device implantation, with or without mastoidectomy  
L8619 Cochlear implant external speech processor, replacement  No 69930 Cochlear device implantation, with or without mastoidectomy  

Drugs

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
J1745 Injection, Infliximab, 10 mg. - Remicade No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J1565 Injection, Respiratory Syncytial Virus Immune Globulin, Intravenous, 50 mg. - Respigam No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3364 Injection, Urokinase, 5000 IU Vial - Abbokinase  No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3365 Injection, Urokinase, 250,000 IU Vial - Abbokinase  No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3488 Injection, Zoledronic Acid (Reclast), 1 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
J7310 Ganciclovir, 4.5 mg., long-acting implant - Vitrasert No 67027 Implantation of intravitreal drug delivery system (eg., ganciclovir, implant), includes concomitant removal of vitreous
J9226 Histrelin Implant (Supprelin LA), 50 mg. No 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

Infusion Pumps

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
EO782 Infusion pump system, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)  No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
    No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
    No 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming
E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
    No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
    No 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming
E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
    No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
    No 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

Neurostimulators

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1767 Generator, neurostimulator (implantable), non-rechargeable No 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 
    No 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays 
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension No 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension  No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling

Osteogenesis Stimulator

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
E0749 Osteogenesis stimulator, electrical, surgically implanted No 20975 Electrical stimulation to aid bone healing; invasive (operative)

Pacemakers

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1785 Pacemaker, dual chamber, rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular 
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
C1786 Pacemaker, single chamber, rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
C2619 Pacemaker, dual chamber, non rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 
C2620 Pacemaker, single chamber, non rate-responsive (implantable)   No 33206 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
C2621 Pacemaker, other than single or dual chamber (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrodes(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 

Skin Replacement

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
Q4101 Skin substitute, Apligraf, per square centimeter No 15340 Tissue cultured allogeneic skin substitute; first 25 sq. cm. or less
    No 15341 Tissue cultured allogeneic skin substitute; each additional 25 sq. cm.