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Contractor Information

Contractor Name ^{back to top}

Palmetto GBA
Contractor Number ^{back to top}
00380
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}

L17742

LCD Title ^{back to top}
Flow Cytometry

Contractor's Determination Number ^{back to top}
04A-0006-L

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, §1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim. 42 CFR, Part 419, Medicare regulations governing Hospital OPPS CMS Pub 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2004, Change Request 3010 Program Memorandum, Transmittal 793, Change Request 2479, November 29, 2002 manualizes payment for services furnished by a CAH.

Primary Geographic Jurisdiction ^{back to top}
South Carolina

Secondary Geographic Jurisdiction ^{back to top}


Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 01/17/2005

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 10/01/2008

Revision Ending Date ^{back to top}
09/02/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Flow cytometry is a complex laboratory process used to examine blood, body fluids, bone marrow, and tissues. Flow cytometry (FCM) counts and analyzes certain characteristics of cells. FCM provides information, including analysis of nuclear DNA content and cell proliferation status. This may help to determine prognosis; aid in the analysis of effusions, urine, or other fluids in which cancer cells may be few or mixed with benign cells; detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. Flow cytometry can rapidly screen large numbers of cells. Solid tissue cells and/or their nuclei are extracted from the tissue and suspended in fluid. Cell nuclei are then stained to assess and quantify nuclear DNA; antibodies with fluorescent molecules attached react with cell antigens to identify or characterize the cells. The suspended cells are forced—one cell at a time—through an adjustable opening and then through a laser light beam. The light activates the fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. An experienced physician, usually a pathologist, performs the clinical analysis and interpretation of the results. Cancer: Flow cytometry may be indicated to help determine the exact diagnosis and/or prognosis of various cancer cell types. Reimbursement is limited to a maximum of 20 flow cytometry markers per date of service. HIV: Flow cytometry may be indicated for the management of patients with HIV infection as defined by the Center for Disease Control criteria. Organ Transplants: Pretransplant determination of antibody level (PRA) or cross match determination as well as postoperative monitoring of organ transplants with flow cytometry may be indicated to determine compatibility, early rejection, immunosuppressive therapy toxicity, or differentiation of infection from allograft rejection. This may require repeated analysis when symptoms are expressed for the above conditions by the transplant patient.

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
18x	Hospital-swing beds
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
73x	Clinic-independent provider based FQHC (eff 10/91)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

030X	Laboratory-general classification

CPT/HCPCS Codes ^{back to top}

88182	FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS
88184	FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER
88185	FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER)
88187	FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS
88188	FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS
88189	FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE MARKERS

ICD-9 Codes that Support Medical Necessity ^{back to top}

042	HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
140.0 - 149.9	MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
150.0 - 159.9	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM
160.0 - 165.9	MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM
170.0 - 176.9	MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - KAPOSI'S SARCOMA UNSPECIFIED SITE
179 - 189.9	MALIGNANT NEOPLASM OF UTERUS-PART UNS - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
190.0 - 199.1	MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
199.2	MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN
200.00 - 200.08	RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.10 - 200.18	LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.20 - 200.28	BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 - 200.38	MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 - 200.48	MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 - 200.58	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 - 200.68	ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 - 200.78	LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.80 - 200.88	OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
201.00 - 201.98	HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 - 202.08	NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.10 - 202.18	MYCOSIS FUNGOIDES UNSPECIFIED SITE - MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20 - 202.28	SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30 - 202.38	MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40 - 202.48	LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50 - 202.58	LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60 - 202.68	MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 - 202.78	PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 - 202.88	OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90 - 202.98	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01	MULTIPLE MYELOMA IN REMISSION
203.02	MULTIPLE MYELOMA, IN RELAPSE
203.10	PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11	PLASMA CELL LEUKEMIA IN REMISSION
203.12	PLASMA CELL LEUKEMIA, IN RELAPSE
203.80	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81	OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
204.00	ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.01	LYMPHOID LEUKEMIA ACUTE IN REMISSION
204.02	ACUTE LYMPHOID LEUKEMIA, IN RELAPSE
204.10	CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.11	LYMPHOID LEUKEMIA CHRONIC IN REMISSION
204.12	CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE
204.20	SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.21	LYMPHOID LEUKEMIA SUBACUTE IN REMISSION
204.22	SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE
204.80	OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.81	OTHER LYMPHOID LEUKEMIA IN REMISSION
204.82	OTHER LYMPHOID LEUKEMIA, IN RELAPSE
204.90	UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.91	UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION
204.92	UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE
205.00	ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.01	MYELOID LEUKEMIA ACUTE IN REMISSION
205.02	ACUTE MYELOID LEUKEMIA, IN RELAPSE
205.10	CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.11	MYELOID LEUKEMIA CHRONIC IN REMISSION
205.12	CHRONIC MYELOID LEUKEMIA, IN RELAPSE
205.20	SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.21	MYELOID LEUKEMIA SUBACUTE IN REMISSION
205.22	SUBACUTE MYELOID LEUKEMIA, IN RELAPSE
205.30	MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.31	MYELOID SARCOMA IN REMISSION
205.32	MYELOID SARCOMA, IN RELAPSE
205.80	OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.81	OTHER MYELOID LEUKEMIA IN REMISSION
205.82	OTHER MYELOID LEUKEMIA, IN RELAPSE
205.90	UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.91	UNSPECIFIED MYELOID LEUKEMIA IN REMISSION
205.92	UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE
206.00	ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.01	MONOCYTIC LEUKEMIA ACUTE IN REMISSION
206.02	ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE
206.10	CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.11	MONOCYTIC LEUKEMIA CHRONIC IN REMISSION
206.12	CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE
206.20	SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.21	MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION
206.22	SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE
206.80	OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.81	OTHER MONOCYTIC LEUKEMIA IN REMISSION
206.82	OTHER MONOCYTIC LEUKEMIA, IN RELAPSE
206.90	UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.91	UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION
206.92	UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE
207.00	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.01	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION
207.02	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE
207.10	CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.11	CHRONIC ERYTHREMIA IN REMISSION
207.12	CHRONIC ERYTHREMIA, IN RELAPSE
207.20	MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.21	MEGAKARYOCYTIC LEUKEMIA IN REMISSION
207.22	MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE
207.80	OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.81	OTHER SPECIFIED LEUKEMIA IN REMISSION
207.82	OTHER SPECIFIED LEUKEMIA, IN RELAPSE
208.00	ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.01	LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION
208.02	ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.10	CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.11	LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION
208.12	CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.20	SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.21	LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN REMISSION
208.22	SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.80	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.81	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION
208.82	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.90	UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.91	UNSPECIFIED LEUKEMIA IN REMISSION
208.92	UNSPECIFIED LEUKEMIA, IN RELAPSE
235.0 - 238.9	NEOPLASM OF UNCERTAIN BEHAVIOR OF MAJOR SALIVARY GLANDS - NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED
273.1	MONOCLONAL PARAPROTEINEMIA
279.10	IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED
279.2	COMBINED IMMUNITY DEFICIENCY
283.2	HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL CAUSES
283.9	ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
284.01	CONSTITUTIONAL RED BLOOD CELL APLASIA
284.09	OTHER CONSTITUTIONAL APLASTIC ANEMIA
284.1	PANCYTOPENIA
284.2	MYELOPHTHISIS
284.81	RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA)
284.89	OTHER SPECIFIED APLASTIC ANEMIAS
285.9	ANEMIA UNSPECIFIED
287.5	THROMBOCYTOPENIA UNSPECIFIED
288.00	NEUTROPENIA, UNSPECIFIED
288.01	CONGENITAL NEUTROPENIA
288.4	HEMOPHAGOCYTIC SYNDROMES
288.60	LEUKOCYTOSIS, UNSPECIFIED
288.61	LYMPHOCYTOSIS (SYMPTOMATIC)
288.62	LEUKEMOID REACTION
288.63	MONOCYTOSIS (SYMPTOMATIC)
288.64	PLASMACYTOSIS
288.65	BASOPHILIA
288.69	OTHER ELEVATED WHITE BLOOD CELL COUNT
288.8	OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS
785.6	ENLARGEMENT OF LYMPH NODES
996.80 - 996.89	COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
V08	ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS
V42.0 - V42.84	KIDNEY REPLACED BY TRANSPLANT - ORGAN OR TISSUE REPLACED BY TRANSPLANT INTESTINES
V49.83	AWAITING ORGAN TRANSPLANT STATUS
V58.44	AFTERCARE FOLLOWING ORGAN TRANSPLANT
V71.1	OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

N/A

General Information

Documentation Requirements ^{back to top}

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

N/A

Sources of Information and Basis for Decision ^{back to top}

Clark GM, et al. Prediction of Relapse or Survival in Patients with Node-negative Breast Cancer by DNA Flow Cytometry. New England Journal of Medicine. 1989; 320: 627-633.

Coon JS and Weinstein RS, ed. Flow Cytometry: Past, Present, and Future. Diagnostic Flow Cytometry. 1991.

DeVita Jr. VT, Hellman S, and Rosenberg SA, eds. Cancer Principles and Practice of Oncology. Philadelphia: Lippincott-Raven; 2001.

Grant GS, et al. Diagnostic and Prognostic Utility of Flow Cytometric DNA Measurements in Follicular Thyroid Tumors. World Journal of Surgery. 1990: 14:283-290.

Jaffe, et al. Functional Abnormalities of CD8+ T Cells Defined a Unique Subset of Patients with Common Variable Immunodeficiency. Blood. July 1993; 82(No. 1):192-201.

Mathews, et al. Function of the Interleukin-2 (IL-2) Receptor v-Chain in Biologic Responses of X-Linked Severe Combined Immunodeficient B Cells to IL-2, IL-4, IL-13, and IL-15. Blood. January 1995; 85(No 1): 38-42.

Muro-Cacho CA. The Role of Immunohistochemistry in the Differential Diagnosis of Soft-Tissue Tumors. Pathology Update. H. Lee Moffitt Cancer Center and Research Institute. Jan/Feb, 1998.

Ochs, et al. Antibody Responses to Bacteriophage (X174 in Patients with Adenosine Deaminase Deficiency. Blood. September 1992; 80 (No. 5): 1163-1171.

Practice Parameters for the Diagnosis and Management of Immunodeficiency (CLIC-AAAAI). Annals of Allergy, Asthma, & Immunology. August 1995: 282-294.

Schmalstieg, et al. Postnatal Development of T Lymphocytes in a Novel X-Linked Immunodeficiency Disease. Clinical Immunology and Immunopathology. July 1992; 64 (No. 1): 71-77.

Wright, et al. Characterization of Common Variable Immunodeficiency: Identification of a Subset of Patients with Distinctive Immunopheonotypic and Clinical Features. Blood. November 1990; 76 (No. 10): 2046-2051.

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with workgroups, which include representatives from the affected provider community. Advisory Committee Meeting Date: N/A.

Start Date of Comment Period ^{back to top}

07/22/2004

End Date of Comment Period ^{back to top}

09/07/2004

Start Date of Notice Period ^{back to top}

12/01/2004

Revision History Number ^{back to top}

Revision #4, 10/01/2008
Revision #3, 10/01/2007
Revision #2, 10/18/2006
Revision #1, 10/01/2006

Revision History Explanation ^{back to top}

Revision #4, 10/01/2008
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2007 to 2008. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes ICD-9 codes 199.2, 203.02, 203.12, 203.82, 204.02, 204.12, 204.22, 204.82, 204.92, 205.02, 205.12, 205.22, 205.32, 205.82, 205.92, 206.02, 206.12, 206.22, 206.82, 206.92, 207.02, 207.12, 207.22, 207.82, 208.02, 208.12, 208.22, 208.82 and 208.92. This revision becomes effective 10/01/2008.

Revision #3, 10/01/2007
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2006 to 2007. Under CMS National Coverage Policy changed the publication number for Change Request 3010 from “100-8” to now read “100-08”. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 200.30-200.38, 200.40-200.48, 200.50-200.58, 200.60-200.68, 200.70-200.78, and 202.70-202.78. ICD-9 code 284.8 was extended to a 5th digit to now read 284.81 and 284.89. During the ICD-9 code annual update review of this Local Coverage Determination (LCD) it was noted that ICD-9 codes 230.0-234.9 were inadvertently added to the LCD. These ICD-9 codes will be deleted. This revision becomes effective 10/01/2007.

Revision #2, 10/18/2006
Under ICD-9 Codes That Do Not Support Medical Necessity changed the verbiage. Under Documentation Requirements added verbiage. This revision becomes effective 10/18/2006.

Revision #1, 10/01/2006
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2005 to 2006. Under CMS National Coverage Policy revised the verbiage. Under Bill Type Codes added 12X, 18X, 21X, 22X, 23X, 71X, and 73X. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 284.01, 284.09, 284.1, 284.2, 288.00, 288.01, 288.4, and 288.60-288.69. Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. Under Advisory Committee Meeting Notes the verbiage was changed. This policy was reviewed for annual validation. This revision becomes effective 10/01/2006.

11/26/2005 - The description for CPT/HCPCS code 88182 was changed in group 1

7/2/2006 - The description for Bill code 14 was changed

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

2/18/2008 - The description for Bill code 21 was changed

08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.

Reason for Change ^{back to top}

ICD9 Addition/Deletion

Last Reviewed On Date ^{back to top}

09/19/2008

Medicare Coverage Database

LCD for Flow Cytometry (L17742)