HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-13-037
Topic:
Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
Section:
Diagnostic Medical
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
March 2017
Annual Review:
March 2017
 
 

Intraoperative neurophysiologic monitoring (IONM) describes a variety of procedures that have been used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

IONM, includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography (EMG) of cranial nerves, electroencephalogram (EEG), and electrocorticography (ECoG), may be considered medically necessary for ANY of the following procedures:

  • Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia; or
  • Resection of epileptogenic brain tissue or tumor; or
  • Resection of brain tissue close to the primary motor cortex and requiring brain mapping; or
  • Protection of cranial nerves during:
    • Resection of tumors involving the cranial nerves; or
    • Cavernous sinus tumors; or
    • Microvascular decompression of cranial nerves: or
    • Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum; or
    • Oval or round window graft; or
  • Endolymphatic shunt for Meniere's disease; or
  • Vestibular section for vertigo; or
  • Correction of scoliosis or deformity of spinal cord involving traction of the cord; or
  • Protection of spinal cord where work is performed in proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions; or
  • Spinal instrumentation requiring pedicle screws or distraction; or
  • Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk; or
  • Spinal cord tumors and spinal fractures (with the risk of cord compression); or
  • Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves; or
  • Surgery or embolization for intracranial arteriovenous malformations (AVMs); or
  • Embolization of bronchial artery AVMs or tumors; or
  • Surgery for arteriovenous malformation of spinal cord; or
  • Cerebral vascular aneurysms; or
  • Surgery for intractable movement disorders; or
  • Arteriography, during which there is a test occlusion of the carotid artery; or
  • Circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., coronary artery bypass grafting (CABG), ventricular aneurysms); or
  • Distal aortic procedures, where there is risk of ischemia to spinal cord; or
  • Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks; or
  • Basal ganglia movement disorders; or
  • Surgery as a result of traumatic injury to spinal cord/brain; or
  • Deep brain stimulation; or
  • Certain thyroid surgeries when there is;
    • Total removal of a complete lobe of the thyroid; or
    • Removal of the entire gland; or
    • Re-entry (re-operation) to a prior surgical field where scar tissue obscures the visual path of the recurrent laryngeal nerve.

Intraoperative neurophysiologic monitoring for any other procedure not listed above is considered not medically necessary.

92585

92586

95829

95860

95861

95863

95864

95867

95868

95907

95908

95910

95911

95912

95913

95925

95926

95927

95928

95929

95937

95938

95939

95940

95941

95955

G0453

 


Neurophysiological studies

Neurophysiological studies may be reimbursed individually whether performed independently or in conjunction with each other.  However, if a provider reports any neurophysiological studies in addition to comprehensive evoked response audiometry, the charges should be combined and processed under code 92585. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

IONM

IONM should be reported under procedure code 95940, 95941, G0453 regardless of the specific monitoring performed (e.g., brainstem auditory evoked response, somatosensory evoked potentials, etc.). If any of the testing codes for neurophysiological monitoring are reported in conjunction with 95940, 95941, G0453 the services should be combined and processed under 95940, 95941, G0453. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Reimbursement is limited to either 95940 (continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary procedure) or 95941 (continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)) per date of service.

92585

95940

95941

G0453


Intraoperative monitoring of visual-evoked potentials is considered experimental/investigational and therefore non-covered, due to a lack of scientific peer reviewed literature.

Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary.

Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental/investigational due to a lack of scientific peer reviewed literature and therefore non-covered.

0464T

95930


C07

C41.2

C41.4

C47.9

C49.3

C70.0

C70.1

C70.9

C71.0

C71.1

C71.2

C71.3

C71.4

C71.5

C71.6

C71.7

C71.8

C71.9

C72.0

C72.1

C72.20

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C72.30

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C72.40

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C72.50

C72.59

C72.9

C73

C79.31

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C79.49

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C79.89

D21.0

D32.0

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D33.0

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D33.3

D33.4

D33.7

D33.9

D36.11

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D42.0

D42.1

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D43.0

D43.1

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D43.8

D43.9

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D49.6

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I65.9

I66.01

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I66.8

I66.9

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I67.1

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M41.9

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M54.15

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M54.30

M54.31

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M96.1

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M96.4

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P11.4

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P11.9

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P14.2

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P14.8

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S06.5X0S

S06.5X1A

S06.5X1D

S06.5X1S

S06.5X2A

S06.5X2D

S06.5X2S

S06.5X3A

S06.5X3D

S06.5X3S

S06.5X4A

S06.5X4D

S06.5X4S

S06.5X5A

S06.5X5D

S06.5X5S

S06.5X6A

S06.5X6D

S06.5X6S

S06.5X7A

S06.5X8A

S06.5X9A

S06.5X9D

S06.5X9S

S06.6X0A

S06.6X0D

S06.6X0S

S06.6X1A

S06.6X1D

S06.6X1S

S06.6X2A

S06.6X2D

S06.6X2S

S06.6X3A

S06.6X3D

S06.6X3S

S06.6X4A

S06.6X4D

S06.6X4S

S06.6X5A

S06.6X5D

S06.6X5S

S06.6X6A

S06.6X6D

S06.6X6S

S06.6X7A

S06.6X8A

S06.6X9A

S06.6X9D

S06.6X9S

S06.890A

S06.890D

S06.890S

S06.891A

S06.891D

S06.891S

S06.892A

S06.892D

S06.892S

S06.893A

S06.893D

S06.893S

S06.894A

S06.894D

S06.894S

S06.895A

S06.895D

S06.895S

S06.896A

S06.896D

S06.896S

S06.897A

S06.898A

S06.899A

S06.899D

S06.899S

S06.9X0A

S06.9X0D

S06.9X0S

S06.9X1A

S06.9X1D

S06.9X1S

S06.9X2A

S06.9X2D

S06.9X2S

S06.9X3A

S06.9X3D

S06.9X3S

S06.9X4A

S06.9X4D

S06.9X4S

S06.9X5A

S06.9X5D

S06.9X5S

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X7A

S06.9X8A

S06.9X9A

S06.9X9D

S06.9X9S

S12.000A

S12.000B

S12.000S

S12.001A

S12.001B

S12.001S

S12.01XS

S12.02XS

S12.030S

S12.031S

S12.040S

S12.041S

S12.090S

S12.091S

S12.100A

S12.100B

S12.100S

S12.101A

S12.101B

S12.101S

S12.110A

S12.110B

S12.110S

S12.111A

S12.111B

S12.111S

S12.112A

S12.112B

S12.112S

S12.120A

S12.120B

S12.120S

S12.130A

S12.130B

S12.130S

S12.131A

S12.131B

S12.131S

S12.14XA

S12.14XB

S12.14XS

S12.150A

S12.150B

S12.150S

S12.151A

S12.151B

S12.151S

S12.190A

S12.190B

S12.190S

S12.191A

S12.191B

S12.191S

S12.200A

S12.200B

S12.200S

S12.201A

S12.201B

S12.201S

S12.230A

S12.230B

S12.230S

S12.231A

S12.231B

S12.231S

S12.24XA

S12.24XB

S12.24XS

S12.250A

S12.250B

S12.250S

S12.251A

S12.251B

S12.251S

S12.290A

S12.290B

S12.290S

S12.291A

S12.291B

S12.291S

S12.300A

S12.300B

S12.300S

S12.301A

S12.301B

S12.301S

S12.330A

S12.330B

S12.330S

S12.331A

S12.331B

S12.331S

S12.34XA

S12.34XB

S12.34XS

S12.350A

S12.350B

S12.350S

S12.351A

S12.351B

S12.351S

S12.390A

S12.390B

S12.390S

S12.391A

S12.391B

S12.391S

S12.400A

S12.400B

S12.400S

S12.401A

S12.401B

S12.401S

S12.430A

S12.430B

S12.430S

S12.431A

S12.431B

S12.431S

S12.44XA

S12.44XB

S12.44XS

S12.450A

S12.450B

S12.450S

S12.451A

S12.451B

S12.451S

S12.490A

S12.490B

S12.490S

S12.491A

S12.491B

S12.491S

S12.500A

S12.500B

S12.500S

S12.501A

S12.501B

S12.501S

S12.530A

S12.530B

S12.530S

S12.531A

S12.531B

S12.531S

S12.54XA

S12.54XB

S12.54XS

S12.550A

S12.550B

S12.550S

S12.551A

S12.551B

S12.551S

S12.590A

S12.590B

S12.590S

S12.591A

S12.591B

S12.591S

S12.600A

S12.600B

S12.600S

S12.601A

S12.601B

S12.601S

S12.630A

S12.630B

S12.630S

S12.631A

S12.631B

S12.631S

S12.64XA

S12.64XB

S12.64XS

S12.650A

S12.650B

S12.650S

S12.651A

S12.651B

S12.651S

S12.690A

S12.690B

S12.690S

S12.691A

S12.691B

S12.691S

S12.9XXA

S12.9XXD

S12.9XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118D

S14.118S

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128D

S14.128S

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151S

S14.152A

S14.152S

S14.153A

S14.153S

S14.154A

S14.154S

S14.155A

S14.155S

S14.156A

S14.156S

S14.157A

S14.157S

S14.158A

S14.158S

S14.159A

S14.159S

S14.2XXA

S14.2XXS

S14.3XXA

S14.3XXS

S14.4XXA

S14.4XXS

S14.5XXA

S14.5XXS

S22.000A

S22.000B

S22.000S

S22.001A

S22.001B

S22.001S

S22.002A

S22.002B

S22.002S

S22.008A

S22.008B

S22.008S

S22.009A

S22.009B

S22.009S

S22.010A

S22.010B

S22.010S

S22.011A

S22.011B

S22.011S

S22.012A

S22.012B

S22.012S

S22.018A

S22.018B

S22.018S

S22.019A

S22.019B

S22.019S

S22.020A

S22.020B

S22.020S

S22.021A

S22.021B

S22.021S

S22.022A

S22.022B

S22.022S

S22.028A

S22.028B

S22.028S

S22.029A

S22.029B

S22.029S

S22.030A

S22.030B

S22.030S

S22.031A

S22.031B

S22.031S

S22.032A

S22.032B

S22.032S

S22.038A

S22.038B

S22.038S

S22.039A

S22.039B

S22.039S

S22.040A

S22.040B

S22.040S

S22.041A

S22.041B

S22.041S

S22.042A

S22.042B

S22.042S

S22.048A

S22.048B

S22.048S

S22.049A

S22.049B

S22.049S

S22.050A

S22.050B

S22.050S

S22.051A

S22.051B

S22.051S

S22.052A

S22.052B

S22.052S

S22.058A

S22.058B

S22.058S

S22.059A

S22.059B

S22.059S

S22.060A

S22.060B

S22.060S

S22.061A

S22.061B

S22.061S

S22.062A

S22.062B

S22.062S

S22.068A

S22.068B

S22.068S

S22.069A

S22.069B

S22.069S

S22.070A

S22.070B

S22.070S

S22.071A

S22.071B

S22.071S

S22.072A

S22.072B

S22.072S

S22.078A

S22.078B

S22.078S

S22.079A

S22.079B

S22.079S

S22.080A

S22.080B

S22.080S

S22.081A

S22.081B

S22.081S

S22.082A

S22.082B

S22.082S

S22.088A

S22.088B

S22.088S

S22.089A

S22.089B

S22.089S

S24.0XXA

S24.0XXS

S24.101A

S24.101S

S24.102A

S24.102S

S24.103A

S24.103S

S24.104A

S24.104S

S24.109A

S24.109S

S24.111A

S24.111S

S24.112A

S24.112S

S24.113A

S24.113S

S24.114A

S24.114S

S24.119A

S24.119S

S24.131A

S24.131S

S24.132A

S24.132S

S24.133A

S24.133S

S24.134A

S24.134S

S24.139A

S24.139S

S24.141A

S24.141S

S24.142A

S24.142S

S24.143A

S24.143S

S24.144A

S24.144S

S24.149A

S24.149S

S24.151A

S24.151S

S24.152A

S24.152S

S24.153A

S24.153S

S24.154A

S24.154S

S24.159A

S24.159S

S24.2XXA

S24.2XXS

S32.000A

S32.000B

S32.000S

S32.001A

S32.001B

S32.001S

S32.002A

S32.002B

S32.002S

S32.008A

S32.008B

S32.008S

S32.009A

S32.009B

S32.009S

S32.010A

S32.010B

S32.010S

S32.011A

S32.011B

S32.011S

S32.012A

S32.012B

S32.012S

S32.018A

S32.018B

S32.018S

S32.019A

S32.019B

S32.019S

S32.020A

S32.020B

S32.020S

S32.021A

S32.021B

S32.021S

S32.022A

S32.022B

S32.022S

S32.028A

S32.028B

S32.028S

S32.029A

S32.029B

S32.029S

S32.030A

S32.030B

S32.030S

S32.031A

S32.031B

S32.031S

S32.032A

S32.032B

S32.032S

S32.038A

S32.038B

S32.038S

S32.039A

S32.039B

S32.039S

S32.040A

S32.040B

S32.040S

S32.041A

S32.041B

S32.041S

S32.042A

S32.042B

S32.042S

S32.048A

S32.048B

S32.048S

S32.049A

S32.049B

S32.049S

S32.050A

S32.050B

S32.050S

S32.051A

S32.051B

S32.051S

S32.052A

S32.052B

S32.052S

S32.058A

S32.058B

S32.058S

S32.059A

S32.059B

S32.059S

S32.10XA

S32.10XB

S32.10XS

S32.110A

S32.110B

S32.110S

S32.111A

S32.111B

S32.111S

S32.112A

S32.112B

S32.112S

S32.119A

S32.119B

S32.119S

S32.120A

S32.120B

S32.120S

S32.121A

S32.121B

S32.121S

S32.122A

S32.122B

S32.122S

S32.129A

S32.129B

S32.129S

S32.130A

S32.130B

S32.130S

S32.131A

S32.131B

S32.131S

S32.132A

S32.132B

S32.132S

S32.139A

S32.139B

S32.139S

S32.14XA

S32.14XB

S32.14XS

S32.15XA

S32.15XB

S32.15XS

S32.16XA

S32.16XB

S32.16XS

S32.17XA

S32.17XB

S32.17XS

S32.19XA

S32.19XB

S32.19XS

S32.2XXA

S32.2XXB

S32.2XXS

S34.01XA

S34.01XS

S34.02XA

S34.02XS

S34.101A

S34.101S

S34.102A

S34.102S

S34.103A

S34.103S

S34.104A

S34.104S

S34.105A

S34.105S

S34.109A

S34.109S

S34.111A

S34.111S

S34.112A

S34.112S

S34.113A

S34.113S

S34.114A

S34.114S

S34.115A

S34.115S

S34.119A

S34.119S

S34.121A

S34.121S

S34.122A

S34.122S

S34.123A

S34.123S

S34.124A

S34.124S

S34.125A

S34.125S

S34.129A

S34.129S

S34.131A

S34.131S

S34.132A

S34.132S

S34.139A

S34.139S

S34.21XA

S34.21XS

S34.22XA

S34.22XS

S34.3XXA

S34.3XXS

S34.4XXA

S34.4XXS

S44.00XA

S44.00XS

S44.01XA

S44.01XS

S44.02XA

S44.02XS

S44.10XA

S44.10XS

S44.11XA

S44.11XS

S44.12XA

S44.12XS

S44.20XA

S44.20XS

S44.21XA

S44.21XS

S44.22XA

S44.22XS

S44.30XA

S44.30XS

S44.31XA

S44.31XS

S44.32XA

S44.32XS

S44.40XA

S44.40XS

S44.41XA

S44.41XS

S44.42XA

S44.42XS

S44.50XA

S44.50XS

S44.51XA

S44.51XS

S44.52XA

S44.52XS

S44.8X1A

S44.8X1S

S44.8X2A

S44.8X2S

S44.8X9A

S44.8X9S

S44.90XA

S44.90XS

S44.91XA

S44.91XS

S44.92XA

S44.92XS

S54.00XA

S54.00XS

S54.01XA

S54.01XS

S54.02XA

S54.02XS

S54.10XA

S54.10XS

S54.11XA

S54.11XS

S54.12XA

S54.12XS

S54.20XA

S54.20XS

S54.21XA

S54.21XS

S54.22XA

S54.22XS

S54.30XA

S54.30XS

S54.31XA

S54.31XS

S54.32XA

S54.32XS

S54.8X1A

S54.8X1S

S54.8X2A

S54.8X2S

S54.8X9A

S54.8X9S

S54.90XA

S54.91XA

S54.92XA

S64.00XA

S64.00XS

S64.01XA

S64.01XS

S64.02XA

S64.02XS

S64.10XA

S64.10XS

S64.11XA

S64.11XS

S64.12XA

S64.12XS

S64.20XA

S64.20XS

S64.21XA

S64.21XS

S64.22XA

S64.22XS

S64.30XA

S64.30XS

S64.31XA

S64.31XS

S64.32XA

S64.32XS

S64.40XA

S64.40XS

S64.490A

S64.490S

S64.491A

S64.491S

S64.492A

S64.492S

S64.493A

S64.493S

S64.494A

S64.494S

S64.495A

S64.495S

S64.496A

S64.496S

S64.497A

S64.497S

S64.498A

S64.498S

S64.8X1A

S64.8X1S

S64.8X2A

S64.8X2S

S64.8X9A

S64.8X9S

S64.90XA

S64.90XS

S64.91XA

S64.91XS

S64.92XA

S64.92XS

S74.00XA

S74.00XS

S74.01XA

S74.01XS

S74.02XA

S74.02XS

S74.10XA

S74.10XS

S74.11XA

S74.11XS

S74.12XA

S74.12XS

S74.20XA

S74.20XS

S74.21XA

S74.21XS

S74.22XA

S74.22XS

S74.8X1A

S74.8X1S

S74.8X2A

S74.8X2S

S74.8X9A

S74.8X9S

S74.90XA

S74.90XS

S74.91XA

S74.91XS

S74.92XA

S74.92XS

S84.00XA

S84.00XS

S84.01XA

S84.01XS

S84.02XA

S84.02XS

S84.10XA

S84.10XS

S84.11XA

S84.11XS

S84.12XA

S84.12XS

S84.20XA

S84.20XS

S84.21XA

S84.21XS

S84.22XA

S84.22XS

S84.801A

S84.801S

S84.802A

S84.802S

S84.809A

S84.809S

S84.90XA

S84.90XS

S84.91XA

S84.91XS

S84.92XA

S84.92XS

S94.00XA

S94.00XS

S94.01XA

S94.01XS

S94.02XA

S94.02XS

S94.10XA

S94.10XS

S94.11XA

S94.11XS

S94.12XA

S94.12XS

S94.20XA

S94.20XS

S94.21XA

S94.21XS

S94.22XA

S94.22XS

S94.30XA

S94.30XS

S94.31XA

S94.31XS

S94.32XA

S94.32XS

S94.8X1A

S94.8X1S

S94.8X2A

S94.8X2S

S94.8X9A

S94.8X9S

S94.90XA

S94.90XS

S94.91XA

S94.91XS

S94.92XA

S94.92XS

T68.XXXA

T68.XXXD

T68.XXXS

T84.216A

T84.216D

T84.216S

T84.226A

T84.226D

T84.226S

T84.296A

T84.296D

T84.296S

T84.310A

T84.310D

T84.310S

T84.318A

T84.318D

T84.318S

T84.320A

T84.320D

T84.320S

T84.328A

T84.328D

T84.328S

T84.390A

T84.390D

T84.390S

T84.398A

T84.398D

T84.398S

Z45.41

Z45.42

Z45.49

 


Place of Service: Inpatient/Outpatient


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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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.

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.