| Effective Date:03/01/2009 |
Title:Vantas (Histrelin)
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| Revision Date:10/01/2015
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Document:BI241:00
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| CPT Code(s):J9225
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
1)
Vantas
requires pre-authorization.
2)
Vantas is a
Histrelin Implant that is covered for advanced prostate cancer.
3)
Vantas is
covered under the medical benefit.
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Medical Statement
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1)
Vantas (Histrelin
Implant) is only covered for the palliative treatment of advanced prostatic
cancer (C61).
2)
Vantas is
contraindicated in females and in pediatric patients.
Codes Used In This BI:
J9225 Vantas Implant
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Limits
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Vantas (Histrelin)
is not covered for other diagnoses.
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Reference
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Intentially left empty
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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