DISCLAIMER

Highmark Health Options 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

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

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 West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for noncovered services and procedures.

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Medical Necessity- The essential need for health care or services which, when delivered by or through authorized and qualified providers, will: Be directly related to the prevention, diagnosis and treatment of a member’s disease, condition, and/or disorder that results in health impairments and/or disability (the physical or mental functional deficits that characterize the member’s condition), and be provided to the member only; Be appropriate and effective to the comprehensive profile (e.g., needs, aptitudes, abilities, and environment) of the member and the member’s family; Be primarily directed to the diagnosed medical condition or the effects of the condition of the member, in all settings for normal activities of daily living (ADLs); Be timely, considering the nature and current state of the member’s diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time; Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of funds; Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member; Be sufficient in amount, scope and duration to reasonably achieve its purpose; Be recognized as either the treatment of choice (i.e., prevailing community or Statewide standard) or common medical practice by the practitioner’s peer group, or the functional equivalent of other care and services that are commonly provided; and Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay.

 

Experimental/Investigational Services- Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case, are determined to be any of the following: Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use. Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational.)

Procedures

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

 

Non-covered services include but are not limited to the services and procedures below:

 

·                Non-Emergent Medical Transportation

·                Medications administered for experimental/investigational purposes;

·                All non-medically necessary services;

·                Sex transformation procedures and hormone therapy associated with sex transformation procedures;

·                Sterilization of a mentally incompetent or institutionalized individual;

·                Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practices, who is responsible for the diagnosis or treatment of a particular patient’s condition;

·                All organ transplants;

·                Acupuncture;

·                Autopsy;

·                Duplicate services;

·                Drugs for weight gain or loss, hair growth, fertility, and cosmetic use;

·                Treatments for infertility and for the reversal of sterilization;

·                Drugs, drug products, and related services, which are defined as a non-covered benefit by BMS’ Outpatient Drug Pharmacy Program;

·                Drugs marketed by a drug company (or labeler) that does not participate in the federal drug rebate program;

·                Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA) Drug Efficacy Study Implementation (DESI);

·                All cosmetic services, except for those provided as a result of accidents or birth defects;

·                Christian Science nurses and sanitariums;

·                Equipment or supplies which are primarily for patient comfort and/or family or caretaker convenience; (Note: One mobility item is covered in a five-year period)

·                Optometry services for individuals over age 21, except the first pair of glasses after cataract surgery;

·                Personal comfort and convenience items or services, whether inpatient/outpatient;(such as television,telephone , barber or beauty service, guest services, and similar incidentak services and supplies, even when prescribed by a physician

·                Radial Keratotomy; Lasik surgery;

·                Services rendered outside the scope of the provider’s license;

·                Fees for missed appointments;

·                Fees to copy medical records;

·                Services rendered by students as a part of their clinical or academic training;

·                Expenses incurred when a patient leaves against medical advice;

·                Abortion

·                Ancillary services and/or services resulting from an office visit not covered by WVCHIP;

·                Aqua therapy;

·                Behavioral health or functional skills training except for ABA treatment;

·                Biofeedback;

·                Coma Stimulation;

·                Court-ordered services that are not covered benefits and/or not medically necessary;

·                Custodial care, domiciliary care, respite care, rest cures or other services primarily to assist in the activities of daily living, or for behavioral modification, including applied behavioral analysis (ABA), except to the extent ABA is mandated to be covered by the mandated treatment of autism spectrum disorder;

·                Daily living skills training

·                Education, training and/or cognitive services unless specifically listed as covered services;

·                Electroconvulsive therapy;

·                Emergency evacuation from a foreign country, even if medically necessary;

·                Expenses for which the member is not responsible, such as patient discounts and contractual discounts;

·                Expenses incurred as a result of the commission of a felony, while incarcerated or while under control of the court system;

·                Family or group therapy when the patient is not present;

·                Genetic testing for screening purposes-except those tests covered under the maternity benefit, are not covered;

·                Implanted hearing aids;

·                Homeopathic medicine;

·                Hospital days associated with non-emergency weekend admissions or under unauthorized hospital days prior to scheduled surgery;

·                Hypnosis;

·                Incidental surgery performed during medically necessary surgery;

·                Non-enrolled providers;

·                Orientation therapy;

·                Orthotropy;

·                Physician conditioning: Expenses related to physical conditioning programs, such as athletic training, body building, exercise, fitness, flexibility, diversion, or general motivation;

·                Service/therapy animals and the associated services and expenses, including training;

·                Sensory Stimulation Therapy (SST); and

·                The difference between private and semiprivate room charges

·                Artificial insemination, in vitro fertilization, infertility services, or sterilization reversal

·                Sterilization for individuals under age 21

·                Weight loss programs or drugs for weight loss

·                Services documented with verbiage exactly like or like previous entries (cloned documentation). This includes photocopying of previous documentation including signatures.

* Enrolled providers cannot bill Medicaid members for missed appointments