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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. |