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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.
POLICYBone allotransplantation is considered medically necessary for procedures that would normally use autologous bone, but where sufficient autologous stock is unavailable.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1999: 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.