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Printer Friendly Version Bone Allotransplantation

Bone Allotransplantation

DESCRIPTION

Bone allografting is intended to treat severe deficiencies in joints and long bones. Allogeneic bone can be implanted in osteoarticular of intercalary sites. Osteoarticular sites consist of joints such as the hip, knee, spine, shoulder, elbow, etc. Intercalary sites are those involving a segment of the shaft of long bones.

Bone allografts may be fresh or preserved by deep freezing or freeze drying.

POLICY

Bone allotransplantation is considered medically necessary for procedures that would normally use autologous bone, but where sufficient autologous stock is unavailable.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

8/1999: Approved by Medical Policy Advisory Committee (MPAC)

3/6/2002: Prior authorization through case management added

4/18/2002: Type of Service and Place of Service deleted

8/5/2005: Code Reference section updated, CPT code 20955, 20962 deleted, CPT code 20930, 20931 "Note: 20930-20931 is the only code range that specified "Allograft." Other codes do not specify autograft or allograft. Most arthroplastics (joint fusion) include bone grafting and do not specify graft type" deleted, ICD-9 procedure code 78.00, 78.01, 78.04, 78.06, 78.08 added, ICD-9 procedure code 81.40, 81.47, 81.49, 81.5, 81.72, 81.75, 81.83 deleted, ICD-9 diagnosis code 715.90-715.98, 721.0-721.9 deleted

10/10/2006: Policy reviewed, prior authorization removed from policy

12/12/2007: Code reference section updated per 2008 CPT/HCPCS revisions

1/7/2009: Policy reviewed, no changes

3/11/2010: Code reference section updated. New HCPCS Codes 0220T and 0221T added to covered table

SOURCE(S)

TEC Evaluation and Coverage 1989: p.3

Blue Cross Blue Shield association policy #7.01.38

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some codes may be variable and coverage will be based on the clinical indication for the service.

Covered Codes

Code Number	Description
CPT-4
20930	Allograft for spine surgery; morselized (List separately in addition to code for primary procedure) (description revised 1/1/2008)
20931	Allograft for spine surgery; structural (List separately in addition to code for primary procedure) (description revised 1/1/2008)
ICD-9 Procedure
78.00, 78.01, 78.02, 78.03, 78.04, 78.05, 78.06, 78.07, 78.08, 78.09	Bone graft code range (78.00, 78.01, 78.04, 78.06, 78.08 added 8-5-2005)
ICD-9 Diagnosis
For coding bone allografts, see the codes for the specific body area involved. Most codes do not specify whether a graft is allogeneic or autologous. There are only a few codes (spine) that differentiate by the type of graft.
HCPCS
0220T	Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic.(new 1-1-2010) Do not report when performed at the same level
0221T	Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar (new1-1-2010) Do not report when performed at the same level

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