CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Radiopharmaceutical Reimbursement

Defines coverage and reimbursement rules for diagnostic and therapeutic radiopharmaceuticals for Blue Cross Blue Shield of Rhode Island products, applying to professional and institutional providers and members covered under BCBSRI benefit contracts.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRadiopharmaceutical Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 20, 2009

Next Review DateN/A

Key ActionObtain preauthorization through the BCBSRI Radiology Management Program vendor for associated imaging tests; if the test is not medically necessary, the radiopharmaceutical is also not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

diagnostic & therapeutictypes of radiopharmaceuticals addressed

professional vs institutionalreimbursement distinction noted

A9500–A9599HCPCS codes range

Radium-223separate policy ref

Coverage and Reimbursement Rules

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRadiopharmaceutical Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 20, 2009

Next Review DateN/A

SourceLink

On This Page

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 only when used as part of a covered service.

Benefits may vary by group/contract; refer to contract benefit booklet or Evidence of Coverage for applicable coverage/benefit details.

ALL of the following

Reimbursement by provider type
- Professional providers: if the radiopharmaceutical is covered as part of a covered service, the service is separately reimbursed.
- Institutional providers: if the radiopharmaceutical is covered as part of a covered service, the service is not separately reimbursed.

When radiopharmaceuticals are used in conjunction with imaging or diagnostic tests, preauthorization through the BCBSRI Radiology Management Program vendor may be required; if the associated test is determined not medically necessary during preauthorization, the radiopharmaceutical is also not medically necessary.

Certain therapeutic radiopharmaceuticals are subject to separate medical policy criteria (for example, Radium-223/Xofigo is governed by its own medical policy).

HCPCS Codes and Coding Notes

Covered HCPCS codes (A9500–A9599) Diagnostic and therapeutic radiopharmaceuticalsHCPCSCovered

A9500	Covered (see add-on crosswalks A9501–A9506)
A9501	HCPCS crosswalk from A9500, line 1
A9502	HCPCS crosswalk from A9500, line 2
A9503	HCPCS crosswalk from A9500, line 3
A9504	HCPCS crosswalk from A9500, line 4
A9505	HCPCS crosswalk from A9500, line 5
A9507	Covered (see add-on crosswalks A9508–A9516)
A9508	HCPCS crosswalk from A9507, line 1
A9509	HCPCS crosswalk from A9507, line 2
A9510	HCPCS crosswalk from A9507, line 3

1–10 of 68

1/7

Therapeutic radiopharmaceuticals (separately reimbursed)HCPCSCovered

A9517	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9527	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9530	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9543	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9563	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9564	Therapeutic radiopharmaceutical - covered and separately reimbursed
A9604	Therapeutic radiopharmaceutical - covered and separately reimbursed
Xofigo	Radium-223 (see separate medical policy for coverage criteria)

Unlisted / Follow unlisted procedures processHCPCS

A9588	Listed with Q9982, Q9983 — follow unlisted procedures process as applicable
Unlisted Radiopharmaceuticals	Follow unlisted procedures process per payer guidance

Provider Requirements and Prior Authorization

Prior Authorization

Obtain preauthorization via BCBSRI Radiology Management Program vendor

Many radiopharmaceuticals used with imaging tests require prior authorization through the BCBSRI Radiology Management Program vendor; if the associated test is determined to be not medically necessary during preauthorization, the radiopharmaceutical is also considered not medically necessary.

Obtain prior authorization for the associated imaging test through the BCBSRI Radiology Management Program vendor when applicable.
If the imaging test is denied as not medically necessary during preauthorization, the radiopharmaceutical will also be denied as not medically necessary.

Key Definitions

Definition — Radiopharmaceuticals

DefinitionRadiopharmaceuticals are products that contain radioactive materials (radioisotopes) administered to image or treat disease by delivering radiation to targeted areas.

Typical administration routesMay be injected (into a vein), taken orally, or placed in/near target tissues.

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

Radiation typesPrimarily deliver alpha and beta particles to target affected areas.