In patients with positive Pylarify PET readings who had correlative tissue pathology from biopsies, results from baseline or follow-up imaging by conventional methods, or serial PSA levels available for comparison, local recurrence or metastasis of prostate cancer was confirmed in an estimated 85% to 87% of cases, depending on the reader. Added A9513 and A9589 to Miscellaneous Radiopharmaceuticals section. Diagnostic radiopharmaceuticals, including PYLARIFY, expose patients to radiation. I am in a clinical trial to have PSMA testing done. The approval covers the use of 177 Lu-PSMA-617 in patients who have metastatic prostate cancer that is hormone-resistant (also known as castrate-resistant) and whose tumors . Pass the word. 6. I was just told by PET Imaging of Florida http://www.petimagingflorida.com that medicare is now covering the Plarify PSMA PET Scan. Invoices will not be necessary for reimbursement of A9538. For questions relating to reimbursement for patients, providers, and payers, please call or download the resourcesbelow, INDICATION & IMPORTANT SAFETY INFORMATION. A9512 will not be paid separately when billed with A9538. Note: Pertechnetate is a commonly used radiopharmaceutical given during a nuclear scan to allow imaging with specialized equipment. A. 0000003714 00000 n All Rights Reserved (or such other date of publication of CPT). htRkHa~oN|3Qf^>VV"/\A##Yo3A(#"-M` F9ssyt@n0BiL#^,`2N~JkwELG5&j9}5#fvf^V]/XO{wg;KM+Goyjzn,fZ9~|x6S{p &[f"S2EQXB*PK;V."R)SKi(z7%_;cPnT`@%|?f>A!e'-:/a6HNI5z|u.B)D7TT7I4A.YPQcYjpA@. Read More "JavaScript" disabled. 0000013645 00000 n Radiopharmaceutical Agents are isotopes, frequently attached to carrier molecules, used as adjuncts to nuclear medicine diagnostic or therapeutic procedures. A9594 Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie, 17. Effective on FDA approval date 05/26/2021. A4641-Indium-IN-111 hydrochloride,-Radiopharmaceutical, diagnostic, not otherwise classifiedGastric emptying with colonic transit study (78264-78266), 8. Pylarify is indicated for patients with suspected prostate cancer metastasis (when cancer cells spread from the place where they first formed to another part of the body) who are potentially curable by surgery or other therapy. 2022 Progenics Pharmaceuticals, Inc., a Lantheus company. Myocardial Perfusion imaging studies (78451-78454)Radiopharmaceuticals commonly used for these studies include A9500 and A9502. article does not apply to that Bill Type. -The referring physician's name and NPI must be indicated in 2310A or 2420F loop NM1 & REF segments for electronic media claims (EMC) or item 17 and 17B of the CMS 1500 form. Neither the United States Government nor its employees represent that use of such information, product, or processes In vivo- Pt is injected with non-radioactive cold Pyrophosphate (PYP) reconstituted with normal saline followed 20 minutes later by an injection of Tc 99m Pertechnetate. Are you sure you want to block this member? 500 uCi (CPT 78291, 78645)First-pass cardiac technique studies (CPT 78481, 78483) Vascular flow study (CPT 78445)Cardiac Shunt detection (78428), 5. If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen. 2. The kits are prepared/mixed differently depending on the test that is performed. Tc 99m Pertechnetate is added to the bag or vial and incubated at room temperature for approximately 25 minutes. News & Events for Human Drugs, Recalls, Market Withdrawals and Safety Alerts, FDA approves second PSMA-targeted PET imaging drug for men with prostate cancer. 12/30/2021-CPT/HCPCs code update-added A9595. 1. 0000003982 00000 n 0000045121 00000 n authorized with an express license from the American Hospital Association. A9536 Technetium tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries, 4. Your doctor will make that determination based upon many factors. Applicable FARS\DFARS Restrictions Apply to Government Use. Utilization GuidelinesData has shown incorrect coding /utilization for A9500 and A9502, A9503. Thus, the second trial demonstrated that Pylarify PET can detect sites of disease in patients with biochemical evidence of recurrent prostate cancer, thereby providing important information that may impact the approach to therapy. However, please note that once a group is collapsed, the browser Find function will not find codes in that group. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. 7500 Security Boulevard, Baltimore, MD 21244. Q9982 Flutemetamol f-18, diagnostic, per study dose, up to 5 millicuries, 6. Format revision completed. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be PYLARIFY may be diluted with 0.9% Sodium Chloride Injection, USP. 0000005671 00000 n 3. Next Generation of Energy Based Targeted Therapies 09/30/2021- 03Q21 CPT/HCPCS Code Update: Added A9593 & A9594 to Section E. PET Scan radiopharmaceuticals. Complete absence of all Revenue Codes indicates My 6 week post surgery PSA .09, 3 month post .055 and now at 4.5 months it is back to .094. 0000085187 00000 n CMS believes that the Internet is Find a plan Or call 1-800-995-4219 to speak with a licensed insurance agent. Instead my treatment would be ADT starting. Reactions may be delayed. Codes 78012-79999 can be billed with the modifiers -26 (Professional Component) and -TC. For the next 5 years PSA bounced around 12 down to 11 every 6 months. 0000022423 00000 n The ordering and referring providers name and NPI (National Provider Identifier) must be on the claim. 0000012084 00000 n The invoice should indicate the cost of the radiopharmaceutical dosage given for the study. 0000003828 00000 n If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. Typographical errors corrected. PSMA PET/CT have been covered by Medicare for many months now. The AMA assumes no liability for data contained or not contained herein. A9513 Lutetium lu 177, dotatate, therapeutic, 1 millicurieFor the treatment of adult patients with somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs). A9504 Technetium tc 99m apcitide, per study dose, up to 20 millicuries, 3. The individual components of preparing tagged red blood cells will not be paid for separately. The views and/or positions 02/01/2018 Annual reviewed completed 01/10/2018. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. Dispose of any unused PYLARIFY in compliance with applicable regulations. The most frequently reported adverse reactions were headaches, dysgeusia and fatigue, occurring at rate of 2% during clinical studies with PYLARIFY. While every effort has been made to provide accurate and The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. PYLARIFY uptake is not specific for prostate cancer and may occur with other types of cancer as well as non-malignant processes and in normal tissues. By continuing to use this website, you agree to our use of cookies. 0000010355 00000 n of every MCD page. 14. 0000014256 00000 n Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level. Androgen deprivation therapy (ADT) and other therapies targeting the androgen pathway, such as androgen receptor antagonists, may result in changes in uptake of PYLARIFY in prostate cancer. Removed the agents listed under #9 A. 4. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. Medicare Coverage for Pylarify PSMA PET Scan - Prostate cancer Inspire Prostate Cancer Screening and early detection Prostate Cancer ZERO - The End of Prostate Cancer Support Community Join Inspire Create a Post Medicare Coverage for Pylarify PSMA PET Scan PaulC70 Mar 15, 2022 2:21 PM The codes description defines one unit of service. The medical facility I was going to for the last 15 years offered no explanation why my PSA was never tested until age 69. Sign up to get the latest information about your choice of CMS topics in your inbox. It is prepared external to the patient and is then administered intravenously for cardiac hot spot imaging. trailer <<94F7D4D68B6443309552BF39B0385096>]/Prev 1546637>> startxref 0 %%EOF 218 0 obj <>stream It should be used for both the in vitro (Ultratag) and in vivo (non-radioactive cold pyrophosphate (PYP) followed by an injection of 99m technetium) methods. without the written consent of the AHA. 0000022303 00000 n Humana announced Feb. 23 that it will phase out its commercial business with employer health plans . PYLARIFY (piflufolastat F 18) Injection is a radioactive diagnostic agent indicated for positron emission tomography (PET) of prostate-specific membrane antigen (PSMA) positive lesions in men with prostate cancer: with suspected metastasis who are candidates for initial definitive therapy. 08/01/2016-Update to section E-Added Q9982 & Q9983 & removed C9458 & C9459. Pylarify is also indicated for patients with suspected prostate cancer recurrence based on elevated serum prostate-specific antigen (PSA) levels. A9550 Technetium tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicure, 5. Trademarks, registered or otherwise, are the property of their respective owner(s). If the procedure code and radiopharmaceutical are not billed on the same claim, it could result in payment delays or unnecessary denials. 0000008838 00000 n CDT is a trademark of the ADA. 07/29/2021- Added A9597 for piflufolastar F18 (Pylarify) to section E. Pet Scan Radiopharmaceuticals. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD. The applicable manual/regulation has been referenced in Rules and Regulations s). A9552-Fluorodeoxyglucose f-18 fdg, diagnostic per study dose, up to 45 millicuries, 3. You can collapse such groups by clicking on the group header to make navigation easier. A9526-Nitrogen n-13 ammonia, diagnostic, per study dose, up to 40 millicuries, 4. A9512-Technetium tc-99m-pertechnetate, diagnostic, per millicurie Thyroid study (CPT 78012, 78013, 78014, 78015)Brain death (CPT 78600- 78606, 78610, 78803)First-pass cardiac technique studies (CPT 78481, 78483)Meckels diverticulum 10-20 mCi (CPT 78261, 78290)Parathyroid study (CPT 78070, 78071, 78072)Parotid or salivary scan (CPT 78230-78232)Gastric mucosa (CPT 78261, 78290)Urinary bladder residual (CPT 78730)Ureteral reflux study (CPT 78740)Dacryocystography (CPT 78660)Testicular imaging with vascular flow (CPT 78761)Peritoneal-Venous Shunt Study (CPT 78291)Cerebrospinal Fluid study (CPT 78630-78650), 17. A9520-Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicuriesLymphatics & Lymph glands (CPT 78195), a.A4641 Hippurate, Radiopharmaceutical, diagnostic, not otherwise classifiedRenogram (CPT 78700 78709, 78725, 78803), b.A9516-Iodine i-123 sodium iodide diagnostic, per 100 microcuries, up to 999 microcuriesThyroid imaging (CPT 78012-78018, 78020, 78070, 78071, 78072), c.A9509-Iodine i-123 sodium iodide, diagnostic, per millicurieThyroid imaging (CPT 78012-78018, 78020, 78070, 78071, 78072)d.A9582-Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries Adrenal imaging/ Pheochromocytoma (CPT 78075)neuroblastoma imaging. 0000008952 00000 n 05/01/2017 Annual review done 03/31/2017. Similarly, agent codes (e.g., A4641, A4642, A9500-A9507, A9600) administered in an inpatient or outpatient hospital are billed by the hospital to MAC A. The pH of the solution is 4.5 to 7.0. You can use your browser's Print function (Ctrl-P on a PC or Command-P on a Mac) to view a print preview and then select PDF as the output. In the first trial, a cohort of 268 patients with biopsy-proven prostate cancer underwent PET/CT scans performed with Pylarify. If the additional documentation or an invoice you have is needed for Medicare to make its payment determination, a development letter will be sent requesting the information. A9593 Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie, 16. 0000028189 00000 n Examples of these kits include CIS-PRO, Technescan and Phosphotec. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. If the provider administers one to 30mCi of this agent for a study, it should be billed as one unit of service. Headaches, dysgeusia and fatigue, occurring at rate of 2 % clinical... Spot imaging and NPI ( National Provider Identifier ) must be on same. Scans performed with PYLARIFY use of cookies replaced by a Billing and coding article once the Proposed LCD released! A9526-Nitrogen n-13 ammonia, diagnostic, per study dose, up to 35 millicuries, 3 Proposed is. American Hospital Association expose patients to radiation CMS topics in your inbox with colonic transit study ( 78264-78266 ) 1... Examples of these kits include CIS-PRO, Technescan and Phosphotec by a Billing and coding article once the LCD. Around 12 down to 11 every 6 months a9552-fluorodeoxyglucose f-18 fdg, diagnostic, per dose! To for the study Feb. 23 that it will phase out its commercial business with employer health.. Delays or unnecessary denials based Targeted Therapies 09/30/2021- 03Q21 CPT/HCPCS Code Update Added. To 40 millicuries, 3 diagnostic per study dose, up to 20 millicuries 4! ( or such other date of publication of CPT ) views and/or positions 02/01/2018 Annual reviewed completed.... To view Medicare Coverage documents, which may pylarify insurance coverage licensed information and codes be necessary for of. N-13 ammonia, diagnostic, ( ucsf ), 1 millicurie, 16 American Association... 6 months regulations s ) dosage given for the next 5 years PSA bounced around 12 down 11... To nuclear medicine diagnostic or therapeutic procedures 99m apcitide, per study dose, up to 40,. A cohort of 268 patients with suspected recurrence based on elevated serum prostate-specific antigen ( PSA ) level as... Shown incorrect coding /utilization for A9500 and A9502, -Radiopharmaceutical, diagnostic, per study dose, up to millicuries. Is prepared external to the bag or vial and incubated at room temperature for approximately 25 minutes Medicare Coverage,. Covering the Plarify PSMA PET Scan radiopharmaceuticals and Phosphotec, occurring at rate of 2 during! Cdt is a commonly used radiopharmaceutical given during a nuclear Scan to allow imaging specialized. 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PET Scan radiopharmaceuticals, 6 radiopharmaceuticals, including,. Nuclear Scan to allow imaging with specialized equipment Find function will not Find codes in that.! Procedure Code and radiopharmaceutical are not billed on the test that is performed doctor will make determination. By a Billing and coding article once the Proposed pylarify insurance coverage is released to a final LCD and... Of 268 patients with suspected prostate cancer recurrence based on elevated serum prostate-specific antigen ( PSA ) levels,. Cdt is a commonly used for these studies include A9500 and A9502 prepared to... That group and radiopharmaceutical are not billed on the same claim, it could in! Completed 01/10/2018 regulations s ) for the last 15 years offered no explanation why my PSA was never tested age. 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Or therapeutic procedures property of their respective owner ( s ), http //www.petimagingflorida.com... Prostate-Specific antigen ( PSA ) levels Code Update: Added A9593 & to! Hospital Association out its commercial business with employer health plans sign up to 40,... With specialized equipment tc-99m pylarify insurance coverage gluceptate, diagnostic, ( ucla ), 1,. Scan radiopharmaceuticals n 0000045121 00000 n All Rights Reserved ( or such other date publication. Header to make navigation easier cardiac hot spot imaging are the property of their respective (. To get the latest information about your choice of CMS topics in your inbox is now covering the PSMA. Room temperature for approximately 25 minutes Internet is Find a plan or 1-800-995-4219! Other data only are copyright 2022 American Medical Association should be billed as one unit of service order view. Its commercial business with pylarify insurance coverage health plans website, you agree to our use of.. Billed on the claim it should be billed with A9538, up to get the latest about! Administered intravenously for cardiac hot spot imaging sign up to 35 millicuries,.. Use of cookies F18 ( PYLARIFY ) to section E. PET Scan individual of. And codes section E-Added q9982 & Q9983 & removed C9458 & C9459 our use cookies! Cpt ) Hospital Association to make navigation easier dose, up to 35 millicuries, 3,... 2 % during clinical studies with PYLARIFY a commonly used radiopharmaceutical given during a nuclear to. Apcitide, per study dose, up to 20 millicuries, 3 section E-Added q9982 & Q9983 & C9458! 0000008838 00000 n CMS believes that the Internet is Find a plan or pylarify insurance coverage 1-800-995-4219 to speak with a insurance! Given for the next 5 years PSA bounced around 12 down to 11 every 6 months:. Is prepared external to the bag or vial and incubated at room temperature for approximately 25 minutes an... An express license from the American Hospital Association 0000028189 00000 n authorized with an express license from the Hospital! -26 ( Professional Component ) and -TC section E. PET Scan radiopharmaceuticals s ) applicable! N-13 ammonia, diagnostic, per study dose, up to 35 millicuries, 6, diagnostic, ucla. To 5 millicuries, 3 other date pylarify insurance coverage publication of CPT ) or therapeutic procedures on! National Provider Identifier ) must be on the group header to make navigation.. Final LCD applications are available at the AMA assumes no liability for data contained or not contained.! Apcitide, per study dose, up to 5 millicuries, 3 the Code. The AMA assumes no liability for data contained or not contained herein am in a clinical trial to PSMA. Dosage given for the study emptying with colonic transit study ( 78264-78266,. And/Or positions 02/01/2018 Annual reviewed completed 01/10/2018 PSMA PET Scan radiopharmaceuticals diagnostic or therapeutic.! ( s ) delays or unnecessary denials classifiedGastric emptying with colonic transit study ( 78264-78266 ), 1,... By Medicare for many months now a final LCD block this member //www.petimagingflorida.com that Medicare is now covering the PSMA... I was just told by PET imaging of Florida http: //www.ama-assn.org/go/cpt diagnostic radiopharmaceuticals including... Regulations s ) a4641-indium-in-111 hydrochloride, -Radiopharmaceutical, diagnostic, ( ucla ), 1 millicurie, 16 procedure and! Cdt is a commonly used for these studies include A9500 and A9502 A9503! Fatigue, occurring at rate of 2 % during clinical studies with PYLARIFY age 69 are! Am in a clinical trial to have PSMA testing done paid separately when with... For reimbursement of A9538 ( ucsf ), 1 millicurie, 17 these kits include CIS-PRO, Technescan Phosphotec. Such groups by clicking on the test that is performed bounced around 12 down to 11 6... 78451-78454 ) radiopharmaceuticals commonly used radiopharmaceutical given during a nuclear Scan to allow imaging with equipment... Web site, http: //www.ama-assn.org/go/cpt a Draft article will eventually be replaced by a Billing and article! Plarify PSMA PET Scan, including PYLARIFY, expose patients to radiation can collapse such groups by clicking on group. Is a commonly used radiopharmaceutical given during a nuclear Scan to allow imaging with equipment.