Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options Duals services for Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic).
Definitions
Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.
Prior Authorization
Prior authorization is not required.
Procedures
Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Local Coverage Article (LCA) information, as well as other CMS sources, using the links below.
Post-payment Audit Statement
The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.
Place of Service
The proper place of service for an Upper Gastrointestinal Endoscopy is outpatient (e.g., physician office, hospital inpatient or outpatient, or an ambulatory surgery center). The Upper Gastrointestinal Endoscopy is only eligible for coverage in an inpatient setting in special circumstances including, but not limited to, the presence of a co-morbid condition that requires monitoring in a more controlled environment.
Coverage Determination and Links
HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD, or the state-specific LCD/LCA.
CMS Link
NCD/LCD Links
· LCD: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350)
Article Link
LCA: Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (A57414)
Reimbursement
Participating facilities will be reimbursed per their HHO Duals contract.
References
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) Endoscopy (100.2). Accessed on December 27, 2023.
Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350). Original Effective date October 1, 2015. Revision Effective date October 17, 2019. Accessed on December 27, 2023.
Centers for Medicare and Medicaid Services (CMS). Local Coverage Article (LCA) Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (A57414). Original Effective date October 1, 2019. Revision Effective date October 1, 2021. Accessed on December 27, 2023.
Contact Us
For questions related to this policy, contact the Highmark Government Market Policy Team at GovernmentPolicy@Highmark.com
