C9150, Xenon xe-129 hyperpolarized gas, diagnostic, per study dose
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of the covered indication: diagnosis and clinical scenario placing member in one of the covered groups (known/prior lung cancer; suspected lung cancer with supporting clinical symptoms such as positive sputum cytology, hemoptysis, unresolved pneumonia, persistent cough, or positive chest X-ray; or prior resected Stage I lung cancer with no metastatic disease at risk for secondary disease)
- Documentation that LIFE will be performed in conjunction with white-light bronchoscopy (WLB) and using the appropriate equipment (policy states Olympus BF-20D flexible fiber optic bronchoscope is indicated)
- Documentation that the treating physician has appropriate training in flexible fiber optic bronchoscopy and training in the use of the LIFE device (per federal restriction noted)
Key Coverage Criteria
- Lung imaging fluorescence endoscopy (LIFE) is medically necessary to enhance the physician's ability to detect and biopsy abnormal bronchial tissue suspicious for pre-cancerous lesions, carcinomas in-situ, and early bronchogenic carcinomas in any of the following groups:
- Members with known or previously diagnosed lung cancer
- Members with suspected lung cancer, including members suspected because of clinical symptoms such as positive sputum cytology, hemoptysis, unresolved pneumonia, persistent cough, or positive chest X-ray
- Members with a previously resected Stage I lung cancer, with no evidence of metastatic disease, who are at risk for secondary disease
- Use of bronchoscopy CPT codes related to the procedure when clinically indicated (listed CPTs 31622, 31623, 31624, 31625, 31628, 31629, 31630, 31631, 31632, 31633, 31635, 31636, 31637, 31638, 31640) when used in appropriate clinical context described above
- Use of ICD-10 diagnoses listed as 'covered if selection criteria are met' when patient meets the stated clinical selection criteria: C34.00–C34.92 (malignant neoplasm of bronchus and lung); C78.00–C78.02 (secondary malignant neoplasm of lung); D02.20–D02.22 (carcinoma in situ of bronchus and lung); D14.30–D14.32 (benign neoplasm of bronchus and lung); D38.1 (neoplasm of uncertain behavior of trachea, bronchus, and lung); J10.00–J10.08, J11.00–J11.08, J12.0–J18.1, J18.8–J18.9 (pneumonia codes); R [...]
1 Active Policy
AETNA-CPB-0581, Lung Imaging: Selected Techniques
Related Codes
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