HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 

Medical Policy:
M-74-014
Topic:
Home Prothrombin Time INR Monitoring for Anticoagulation Management
Section:
Diagnostic Medical
Effective Date:
November 4, 2019
Issued Date:
January 6, 2020
Last Revision Date:
October 2019
Annual Review:
October 2019
 
 

Use of the International Normalized Ratio (INR) or prothrombin time (PT) – standard measurement for reporting the blood's clotting time – allows physicians to determine the level of anticoagulation in a individual, independent of the laboratory reagents used. The INR is the ratio of the individual’s PT (extrinsic or tissue-factor coagulation pathway) compared to the mean PT for a group of normal individuals.

Policy Position

The use of home PT/INR monitoring for chronic, oral anticoagulation management may be considered medically necessary for when ALL of the following criteria are met:

·         The individual has ONE of the following:

o    Mechanical heart valves; or

o    Chronic atrial fibrillation; or

o    Venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism); and

·         The individual is currently taking Warfarin; and

·         The individual must have been anticoagulated for at least three (3) months prior to use of the home INR device; and

·         The individual must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and

·         The individual continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and

·         Self-testing with the device should not occur more frequently than once a week; and

·         The monitor and the home testing must be prescribed by a treating physician.

The use of home PT/INR will not be considered medically necessary for any other indications.

Payment will not be made for home INR monitoring for individuals with porcine valves.

 

 

93792

93793

G0248

G0249

G0250

 

 

 




Procedure code G0249 includes payment for both the device and the supplies. These items may not be separately billed. Procedure code G0249 includes materials for four (4) tests. Therefore, this code should not be billed more than once every four (4) weeks.

Procedure code G0250 is per four (4) tests. Self-testing with the INR monitor is limited to once weekly. Therefore, this code should not be billed more than once every four (4) weeks. 


Covered Diagnosis Codes for Procedure Codes 93792 93793 G0248 G0249 G0250

D68.51 

D68.52 

D68.59 

D68.61 

D68.62 

I26.01  

I26.02  

I26.09  

I26.90  

I26.92  

I26.93

I26.94

I26.99  

I48.0    

I48.11

I48.19

I48.20

I48.21

I48.91

I80.00  

I80.01  

I80.02  

I80.03  

I80.10  

I80.11  

I80.12  

I80.13  

I80.201 

I80.202 

I80.203 

I80.209 

I80.211 

I80.212 

I80.213 

I80.219 

I80.221 

I80.222 

I80.223 

I80.229 

I80.231 

I80.232 

I80.233 

I80.239 

I80.241

I80.242

I80.243

I80.249

I80.251

I80.252

I80.253

I80.259

I80.291 

I80.292 

I80.293 

I80.299 

I80.3    

I80.8

I80.9    

I82.0    

I82.1    

I82.220 

I82.221

I82.3    

I82.401 

I82.402 

I82.403 

I82.409 

I82.411 

I82.412 

I82.413 

I82.419 

I82.421 

I82.422 

I82.423 

I82.429 

I82.431 

I82.432 

I82.433 

I82.439 

I82.441 

I82.442 

I82.443 

I82.449 

I82.451

I82.452

I82.453

I82.459

I82.461

I82.462

I82.463

I82.469

I82.491 

I82.492 

I82.493 

I82.499 

I82.4Y1

I82.4Y2

I82.4Y3

I82.4Y9

I82.4Z1

I82.4Z2

I82.4Z3

I82.4Z9

I82.91  

T80.0XXA

T81.718A

T81.72XA

T82.817A

T82.818A

Z79.01 

Z95.2

 

 



Place of Service: Outpatient

Home PT INR Monitoring for Anticoagulation Management is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.