CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Radiopharmaceuticals reimbursement

This policy governs coverage and reimbursement for diagnostic and therapeutic radiopharmaceuticals for BlueCHiP for Medicare and Commercial products and explains when radiopharmaceuticals are covered as part of a covered service.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRadiopharmaceuticals reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective Date10|20|2009

Next Review DateN/A

Key ActionObtain preauthorization through the BCBSRI Radiology Management Program vendor when radiopharmaceuticals are used with tests that require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

listedHCPCS codes enumerated

may applyPreauthorization

separately reimbursedProfessional reimbursement

not separately reimbursedInstitutional reimbursement

Coverage Conditions for Radiopharmaceuticals

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Radiopharmaceuticals are covered when used as part of a covered service.

If the radiopharmaceutical is used with a test that requires preauthorization through the BCBSRI Radiology Management Program vendor, the preauthorization requirements for the underlying test apply; if the underlying test is determined not medically necessary during preauthorization, the radiopharmaceutical is also not medically necessary.

Benefits may vary between groups/contracts; refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific diagnostic imaging, lab, machine test and therapeutic radiology coverage/benefits.

Reimbursement by provider type

Professional providers: if the service is covered, the radiopharmaceutical is separately reimbursed.
Institutional providers: if the service is covered, the radiopharmaceutical is not separately reimbursed.

Some listed therapeutic radiopharmaceuticals (e.g., Radium-223, HCPCS A9606) are subject to separate medical policies for coverage criteria; follow related policy guidance where indicated.

HCPCS Codes and Reimbursement by Provider Type

Diagnostic Radiopharmaceutical HCPCS Codes (covered)HCPCSCovered

A9500	Diagnostic radiopharmaceutical - see specific modifiers for multi-dose units
A9501	Diagnostic radiopharmaceutical
A9502	Diagnostic radiopharmaceutical
A9503	Diagnostic radiopharmaceutical
A9507	Diagnostic radiopharmaceutical
A9508	Diagnostic radiopharmaceutical
A9509	Diagnostic radiopharmaceutical
A9510	Diagnostic radiopharmaceutical
A9512	Diagnostic radiopharmaceutical
A9515	Diagnostic radiopharmaceutical

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Reimbursement by Provider Type

Professional ProvidersIf covered, service is separately reimbursed

Institutional ProvidersIf covered, service is not separately reimbursed

Prior Authorization and Provider Requirements

Prior Authorization

Link radiopharmaceuticals to radiology preauthorization

Radiopharmaceuticals used with imaging/tests that require preauthorization must be included in the preauthorization request to the BCBSRI Radiology Management Program vendor; if the underlying test is denied as not medically necessary during preauthorization, the radiopharmaceutical is also considered not medically necessary.

Submit preauthorization for the associated test through the BCBSRI Radiology Management Program vendor and include the radiopharmaceutical as part of the request.
If the preauthorization determination finds the underlying test not medically necessary, the radiopharmaceutical will also be deemed not medically necessary.

Key Definitions

Radiopharmaceuticals

DefinitionRadiopharmaceuticals are drugs that contain radioactive materials (radioisotopes) administered intravenously, orally, or into a body cavity to image or treat disease by emitting alpha and beta particles.

Typical useMost often used in small amounts for imaging tests; larger doses may be used therapeutically to deliver radiation to treat cancer or relieve symptoms.

Routes of administrationMay be given by vein, taken by mouth, or placed in a body cavity.

Examples in policyIncludes diagnostic HCPCS codes A9500–A9577 and related codes; therapeutic examples include A9517, A9527, A9530, A9543, A9563, A9564, A9590, A9600, A9604, and A9606 (Radium-223 referenced).