Reimbursement for DaTscan

GE Healthcare

Reimbursement for DaTscan

DaTscan is a radiopharmaceutical indicated for striatal dopamine transporter visualization using single-

photon emission computed tomography (SPECT) brain imaging to assist in the evaluation of adult patients with suspected parkinsonian syndromes (PS). In these patients, healthcare providers may use DaTscan imaging to help differentiate essential tremor from tremor due to PS (idiopathic Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy). DaTscan is an adjunct to other diagnostic evaluations. CONTRAINDICATIONS: DaTscan is contraindicated in patients with known hypersensitivity to the active substance, any of the excipients, or iodine.1

Please see Product Indications and Important Risk and Safety Information About DaTscan and the Full Prescribing Information for DaTscan before use.

Coding Information

To receive appropriate reimbursement, physicians should report the appropriate HCPCS code for the product along with the appropriate CPT? code for the procedure. Some payers may require the National Drug Code (NDC) for DaTscan, which is 17156-210-01.

Code

Description

HCPCS: A9584

Iodine I-123 ioflupane, diagnostic, per-study dose, up to 5 millicuries

CPT?: 78607

Brain imaging, tomographic (SPECT)

Common Diagnosis Codes

Diagnosis and procedure coding are at the discretion of the physician based on the clinical condition of the patient, the nature of thephysician's findings, and the procedural steps dictated in the patient's medical record. Only the physician can determine a diagnosis.Because policies vary, verification of covered diagnosis is recommended. Some examples could be:

Reimbursement for DaTscan

ICD-9-CM Diagnosis Code Description

332.0

Paralysis agitans

332.1

Secondary parkinsonism

333.1 781.0

Essential and other specified forms of tremor

Tremor/Parkinson's

ICD-10-CM G20 G21.11 G21.19 G21.8 G25.0 G25.1 G25.2 R25.0 R25.1 R25.2 R25.3 R25.4

Description Parkinson's disease Neuroleptic-induced parkinsonism Other drug-induced secondary parkinsonism Other secondary parkinsonism Essential tremor Drug-induced tremor Other specified forms of tremor Abnormal head movement Tremor unspecified Cramp or spasm Fasciculation Unspecified abnormal involuntary movement

Because coverage criteria vary by payer, providers are encouraged to check with the specific plan for specific covered diagnosis codes. Individual benefit plans may vary.

Reimbursement for DaTscan

Common Diagnosis Codes

Payer National Aetna Health Inc. Cigna Humana

Coverage (policy#, effective date) Yes (0307, March 20, 2015)

No policy but pays case-by-case*

Yes Yes

Blue Cross Blue Shield

State Plan Name

DC

CareFirst BCBS

FL

BCBS of Florida

HI

BCBS of Hawaii (HMSA)

IL

BCBS Illinois/Health Care Services Corp. (HCSC)

IO

Wellmark BCBS

KS

BCBS of Kansas

MD

CareFirst BCBS

MI

BCBS of Michigan

Coverage (policy#, effective date)

Yes (Policy # NA, 7/1/13)

No policy but pays case-by-case* Yes Yes Yes Yes Yes Yes Yes

Reimbursement for DaTscan

Common Diagnosis Codes

Blue Cross Blue Shield

State MN MO MT ND NE NM NY OK SC SD TN TX VA VT

Plan Name BCBS of Minnesota BCBS of Kansas City BCBS Montana/Health Care Services Corp. (HCSC) BCBS of North Dakota BCBS of Nebraska BCBS New Mexico/Health Care Services Corp. (HCSC) Excellus BCBS BCBS Oklahoma/Health Care Services Corp. (HCSC) BCBS of South Carolina Wellmark BCBS BCBS of Tennessee BCBS Texas/Health Care Services Corp. (HCSC) CareFirst BCBS BCBS of Vermont

Coverage (policy#, effective date)

*It is recommended to follow predetermination protocols in place with the insurer prior to ordering the procedure.

No policy but pays case-by-case* Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Reimbursement for DaTscan

Medicare Coverage

First Coast Service Options (FCSO)

CAHABA

AL, GA, TN

State

LCD in place (Policy #,Date)

Reimbursed Yes

CIGNA Government Services CGS KY, OH

Yes

First Coast Service Options (FCSO) FL, PR, VI

Yes

National Government Services (NGS) IN, MN, WI, IL, CT, NY, ME, VT, NH, MA, RI

Yes

Noridian

AK, CA, HI, WA, AZ, MT, ND, OR, SD, UT, WY, ID, NV

Yes

Novitas

DC, DE, MD, NJ, PA, CO, NM, OK, TX, AR, LA, MS

Yes

Palmetto GBA

SC, WV, VA, NC

Yes

Wisconsin Physician Services (WPS) IA, KS, MO, NE, MI, IN

Y (L31361, March 1, 2013)

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