About this policy
Jurisdiction: JJ Part B. States: Alabama, Georgia, Tennessee. Type: Active LCD
Coverage indications
The use of a scalp hypothermia device that has been approved by the United States (U.S.) Food and Drug Administration (FDA) for the prevention of chemotherapy-induced alopecia (CIA) shall be considered reasonable and necessary for patients with solid tumors. The device is contraindicated for pediatric patients, patients with certain cancers and patients undergoing specific chemotherapy treatments. Usage of the device is contraindicated in: Central nervous system malignancies (either primary or metastatic) Squamous cell carcinoma and small cell carcinoma of the lung Skin cancers including melanoma, squamous cell carcinoma, and Merkel cell carcinoma Patients who are scheduled for bone marrow ablation chemotherapy Patients who are scheduled to undergo skull irradiation or have previously received skull irradiation Patients with a history of scalp metastases, or in whom scalp metastases are suspected Patients with cold sensitivity, cold agglutinin disease, cryoglobulinemia, cryofibrinogenemia, and post-traumatic cold dystrophy Patients with severe liver or renal disease from any etiology who may not be able to metabolize or clear the metabolites of the chemotherapeutic agent Patients with hematologic malignancies (leukemia, non-Hodgkin and other generalized lymphomas)
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 97007 | CPT | Covered |
| 97008 | CPT | Covered |
| 97009 | CPT | Covered |
| C00.0 | ICD10CM | Covered |
| C00.1 | ICD10CM | Covered |
| C00.2 | ICD10CM | Covered |
| C00.3 | ICD10CM | Covered |
| C00.4 | ICD10CM | Covered |
| C00.5 | ICD10CM | Covered |
| C00.6 | ICD10CM | Covered |
| C00.8 | ICD10CM | Covered |
| C00.9 | ICD10CM | Covered |