Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Results reflect not only on the integrity of the functioning connection between a nerve and its innervated muscle, but also on the integrity of a muscle itself.
Nerve conduction velocity (NCV) also called nerve conduction study (NCS) is the study of a nerve being stimulated electronically through the skin and underlying tissue to measure nerve conduction time. Results of NCV studies reflect on the integrity and function of the myelin sheath and the axon of the nerve.
EMG and NCV studies are commonly performed in conjunction with each other to confirm a clinical diagnosis of the peripheral nervous system disorders.
Neuromuscular junction testing (repetitive stimulation) involves recording muscle responses to a series of nerve stimuli applied at differing rates, both before and after exercise or transmission of high-frequency stimuli. Testing may be performed in addition to NCS of the same nerves and/or EMG. Testing is indicated for suspected diseases of the neuromuscular junction (generally associated with progressive motor fatigability) which include myopathy, focal neuropathy, Myasthenia gravis and Lambert Eaton Myasthenic syndrome. Another condition that testing may be indicated for, botulism, is associated with a decrease in the amount of acetylcholine released, and results in weakness.
EMG may be considered medically necessary for any ONE of the following conditions:
EMG for any other indication is considered not medically necessary.
95860 |
95861 |
95863 |
95864 |
95865 |
95867 |
95868 |
95869 |
95870 |
95872 |
95885 |
95886 |
95887 |
|
NCV studies may be considered medically necessary for ANY of the following conditions:
NCV is considered not medically necessary for any other indications.
95907 |
95908 |
95909 |
95910 |
95911 |
95912 |
95913 |
95937 |
|
|
|
|
|
|
An H-reflex test can be paid separately from any EMG studies and NCV studies listed and should be limited to one unilateral or bilateral study per session per code.
An F-Wave is considered a form of nerve conduction testing. When reported independently, it should be processed according to the number of nerves studied.
Payment higher than the established allowance for an NCV study should not be made if a doctor reports that multiple methods (e.g., surface and needle electrodes) or multiple sites were used, or that an anatomical crossover existed (e.g., a median nerve is stimulated but the ulnar nerve is affected). None of these constitute a circumstance of such an unusual nature as to warrant additional payment.
95907 |
95908 |
95909 |
95910 |
95911 |
95912 |
95913 |
Electrodiagnostic assessment consisting of EMG and NVC may be considered medically necessary as an adjunct to history, physical exam and imaging studies when the following criteria are met and when performed together and interpreted on the same day for ANY of the following conditions:
· Generalized myopathy, including but not limited to ANY of the following:
o Polymyositis; or
o Dermatomyositis; or
o Myotonic myopathy; or
o Congenital myopathy; or
o Muscular dystrophies; or
· Plexopathies
o Cervical; or
o Brachial; or
o Lumbosacral; or
· Focal neuropathy, entrapment neuropathy, compressive lesion/syndrome, including but not limited to any of the following:
o Carpel tunnel; or
o Cubital tunnel syndrome; or
o Tarsal tunnel syndrome; or
o Ulnar nerve entrapment; or
o Peroneal nerve compression; or
o Thoracic outlet syndrome; or
o Other peripheral nerve entrapments; or
· Generalized neuropathy or confirmed diagnosis including but not limited to any ONE of the following:
o Metabolic and nutritional (diabetic, uremic, amyloidosis, hypothyroidism, immune, vitamin B12 or thiamine deficiency); or
o Toxic neuropathy (e.g. vincristine, amiodarone); or
o Hereditary polyneuropathy (Charcot-Marie tooth Disease); or
o Demyelinating polyneuropathies;
§ Guillain-Barre' syndrome (acute); or
§ Chronic idiopathic demyelinating polyneuropathy; or
o Idiopathic peripheral neuropathy; or
o When used as a diagnostic aid in the evaluation of signs/symptoms suggestive of diabetic or uremic neuropathy; or
o Alcohol-related neuropathy; or
· Traumatic peripheral nerve lesion; or
· Nerve root, peripheral nerve, muscle, or neuromuscular junction involvement with symptom- based presentation and pre-test evaluations are inconclusive and clinical assessment supports the need for the study, such as for ANY of the following:
o Muscle weakness; or
o Muscle atrophy; or
o Muscle fasciculation; or
o Myokymia (involuntary twitching of the eyelid muscles); or
o Myotonia; or
o Loss of dexterity; or
o Spasticity; or
o Hyperreflexia; or
o Sensory deficits; or
o Diplopia; or
o Ptosis; or
o Swallowing dysfunction; or
o Dysarthria; or
o Impaired bowel motility; or
· Motor neuron disease
o Amyotrophic lateral sclerosis; or
o Progressive muscular atrophy; or
o Progressive bulbar palsy; or
o Pseudobulbar palsy; or
o Primary lateral sclerosis; or
· Spine disorder and BOTH of the following:
o Appropriate imaging studies (e.g., CT scan, MRI, myelogram) confirming nerve root impingement; and any ONE of the following:
§ To differentiate radiculopathy from other neuropathies or non-neuropathic processes; or
§ To establish whether imaging findings are responsible for reported pain; or
§ To reconcile when pattern of pain, sensory impairment, or weakness does not match imaging findings; or
§ To document degree of axonal nerve damage in an individual with weakness.
A repeat electrodiagnostic assessment may be considered medically necessary when at least ONE of the following criteria have been met:
· Development of new symptoms or signs suggesting a second diagnosis in a patient who has received an initial diagnosis; or
· Interim progression of disease following an initial test that was inconclusive, such that a repeat test is likely to elicit additional findings; or
· Unexpected change(s) in the course of disease or response to treatment, suggesting that the initial diagnosis may be incorrect and that reexamination is indicated.
Electrodiagnostic assessment consisting of EMG and NVC for any other indications is considered not medically necessary.
95860 |
95861 |
95863 |
95864 |
95907 |
95908 |
95909 |
95910 |
95911 |
95912 |
95913 |
|
|
|
Repetitive Nerve Stimulation (RNS) in the diagnosis of a neuromuscular junction disease may be considered medically necessary for the following conditions:
RNS for any other indication is considered not medically necessary.
Neuromuscular junction testing (repetitive stimulation) should be processed separately and should be limited to two repetitive stimulations per session.
95937
The following tests are considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the use of these tests.
95905 |
95999 |
0106T |
0107T |
0108T |
0109T |
0110T |
S3900 |
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|
|
|
|
Recommended Maximum Number of Electrodiagnostic Studies for Specific Diagnosis
|
Indication |
Needle EMG |
NCS |
Other Studies |
||
|
|
No. of tests |
Motor NCS ±F Wave |
Sensory NCS |
H-Reflex |
RNS Testing |
|
Carpal tunnel Syndrome (Unilateral) |
1 |
3 |
4 |
0 |
0 |
|
Carpel tunnel (bilateral) |
2 |
4 |
6 |
0 |
0 |
|
Radiculopathy |
2 |
3 |
2 |
2 |
0 |
|
Mononeuropathy |
1 |
3 |
3 |
2 |
0 |
|
Polyneuropathy/mononeuropathy multiplex |
3 |
4 |
4 |
2 |
0 |
|
Myopathy |
2 |
2 |
2 |
0 |
2 |
|
Motor neuropathy (e.g. ALS) |
4 |
4 |
2 |
0 |
2 |
|
Plexopathy |
2 |
4 |
6 |
2 |
0 |
|
Neuromuscular Junction |
2 |
2 |
2 |
0 |
3 |
|
Tarsal tunnel syndrome (unilateral) |
1 |
4 |
4 |
0 |
0 |
|
Tarsal tunnel syndrome (bilateral) |
2 |
5 |
6 |
0 |
0 |
|
Weakness, fatigue, cramps, or twitching (focal) |
2 |
3 |
4 |
0 |
2 |
|
Weakness, fatigue, cramps, or twitching (general) |
4 |
4 |
4 |
0 |
2 |
|
Pain, numbness, or tingling (focal) |
1 |
3 |
4 |
2 |
0 |
|
Pain, numbness, or tingling (general) |
2 |
4 |
6 |
2 |
0 |
Refer to medical policy M-13 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring) for additional information.
Refer to medical policy I-11 Botulinum Toxin (Chemodenervation) for additional information.
The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis. If prognostic information is required on ultimate vocal fold mobility in a patient with vocal fold paralysis that is greater than four (4) weeks and less than six (6) months in duration, LEMG should be performed. LEMG may be performed to clarify treatment decisions in a patient with vocal fold immobility that is presumed to be caused by RLN
COVERED DIAGNOSIS CODES FOR PROCEDURES CODES: 95860, 95861, 95863, 95864, 95865, 95869, 95870, 95872, 95885, 95886, 95887, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937
A05.1 |
B02.21 |
B02.22 |
B02.23 |
E10.40 |
E10.41 |
E10.42 |
E10.43 |
E10.44 |
E10.49 |
E11.40 |
E11.41 |
E11.42 |
E11.43 |
E11.44 |
E11.49 |
E13.40 |
E13.41 |
E13.42 |
E13.43 |
E13.44 |
E13.49 |
E51.9 |
G04.1 |
G11.4 |
G11.8 |
G11.9 |
G12.0 |
G12.1 |
G12.8 |
G12.9 |
G12.20 |
G12.21 |
G12.22 |
G12.29 |
G50.0 |
G50.1 |
G50.8 |
G50.9 |
G51.4 |
G51.8 |
G51.9 |
G52.1 |
G52.2 |
G52.3 |
G52.7 |
G52.8 |
G52.9 |
G53 |
G54.0 |
G54.1 |
G54.2 |
G54.3 |
G54.4 |
G54.5 |
G54.6 |
G54.7 |
G54.8 |
G54.9 |
G55 |
G56.01 |
G56.02 |
G56.03 |
G56.11 |
G56.12 |
G56.13 |
G56.21 |
G56.22 |
G56.23 |
G56.31 |
G56.32 |
G56.33 |
G56.41 |
G56.42 |
G56.43 |
G56.81 |
G56.82 |
G56.83 |
G56.91 |
G56.92 |
G56.93 |
G57.01 |
G57.02 |
G57.03 |
G57.11 |
G57.12 |
G57.13 |
G57.20 |
G57.21 |
G57.22 |
G57.23 |
G57.31 |
G57.32 |
G57.33 |
G57.41 |
G57.42 |
G57.43 |
G57.51 |
G57.52 |
G57.53 |
G57.61 |
G57.62 |
G57.63 |
G57.71 |
G57.72 |
G57.73 |
G57.81 |
G57.82 |
G57.83 |
G57.91 |
G57.92 |
G57.93 |
G58.0 |
G58.7 |
G58.8 |
G58.9 |
G59 |
G60.0 |
G60.1 |
G60.2 |
G60.3 |
G61.0 |
G61.1 |
G61.81 |
G61.82 |
G62.0 |
G62.1 |
G62.2 |
G62.9 |
G62.82 |
G62.89 |
G63 |
G64 |
G65.0 |
G65.1 |
G65.2 |
G70.1 |
G70.2 |
G70.9 |
G70.00 |
G70.01 |
G70.80 |
G70.81 |
G71.0 |
G71.2 |
G71.3 |
G71.8 |
G71.9 |
G71.11 |
G71.12 |
G71.13 |
G71.14 |
G71.19 |
G72.0 |
G72.1 |
G72.2 |
G72.3 |
G72.41 |
G72.49 |
G83.81 |
G83.82 |
G83.83 |
G83.84 |
G83.89 |
G90.09 |
G90.2 |
G90.4 |
G90.50 |
G90.511 |
G90.512 |
G90.513 |
G90.519 |
G90.521 |
G90.522 |
G90.523 |
G90.529 |
G90.59 |
G90.8 |
G90.9 |
J38.01 |
J38.02 |
M05.49 |
M05.59 |
M05.411 |
M05.412 |
M05.421 |
M05.422 |
M05.431 |
M05.432 |
M05.441 |
M05.442 |
M05.451 |
M05.452 |
M05.461 |
M05.462 |
M05.471 |
M05.472 |
M05.511 |
M05.512 |
M05.521 |
M05.522 |
M05.531 |
M05.532 |
M05.541 |
M05.542 |
M05.551 |
M05.552 |
M05.561 |
M05.562 |
M05.571 |
M05.572 |
M21.371 |
M21.372 |
M21.379 |
M21.331 |
M21.332 |
M21.511 |
M21.512 |
M21.531 |
M21.532 |
M21.541 |
M21.542 |
M21.549 |
M25.511 |
M25.512 |
M25.521 |
M25.522 |
M25.531 |
M25.532 |
M25.551 |
M25.552 |
M25.561 |
M25.562 |
M25.711 |
M25.712 |
M33.00 |
M33.01 |
M33.02 |
M33.09 |
M33.10 |
M33.11 |
M33.12 |
M33.19 |
M33.20 |
M33.21 |
M33.22 |
M33.29 |
M33.90 |
M33.91 |
M33.92 |
M33.99 |
M34.82 |
M34.83 |
M35.3 |
M35.4 |
M35.8 |
M35.03 |
M36.0 |
M47.11 |
M47.12 |
M47.13 |
M47.14 |
M47.15 |
M47.16 |
M47.20 |
M47.21 |
M47.22 |
M47.23 |
M47.24 |
M47.25 |
M47.26 |
M47.27 |
M47.28 |
M48.061 |
M48.062 |
M51.14 |
M51.15 |
M51.16 |
M51.17 |
M54.2 |
M54.5 |
M54.11 |
M54.12 |
M54.13 |
M54.14 |
M54.15 |
M54.16 |
M54.17 |
M54.18 |
M54.30 |
M54.31 |
M54.32 |
M54.40 |
M54.41 |
M54.42 |
M62.9 |
M79.601 |
M79.602 |
M79.604 |
M79.605 |
M79.621 |
M79.622 |
M79.631 |
M79.632 |
M79.641 |
M79.642 |
M79.644 |
M79.645 |
M79.651 |
M79.652 |
M79.661 |
M79.662 |
M79.671 |
M79.672 |
M79.674 |
M79.675 |
R20.0 |
R20.1 |
R20.2 |
R20.3 |
R20.8 |
R20.9 |
R25.2 |
R29.0 |
S12.100K |
S12.100S |
S12.101A |
S12.101B |
S12.101D |
S12.101G |
S12.101K |
S12.101S |
S12.200A |
S12.200B |
S12.200D |
S12.200G |
S12.200K |
S12.200S |
S12.201A |
S12.201B |
S12.201D |
S12.201G |
S12.201K |
S12.201S |
S12.300A |
S12.300B |
S12.300D |
S12.300G |
S12.300K |
S12.300S |
S12.301A |
S12.301B |
S12.301D |
S12.301G |
S12.301K |
S12.301S |
S12.400A |
S12.400B |
S12.400D |
S12.400G |
S12.400K |
S12.400S |
S12.401A |
S12.401B |
S12.401D |
S12.401G |
S12.401K |
S12.401S |
S12.500A |
S12.500B |
S12.500D |
S12.500G |
S12.500K |
S12.500S |
S12.501A |
S12.501B |
S12.501D |
S12.501G |
S12.501K |
S12.501S |
S12.600A |
S12.600B |
S12.600D |
S12.600G |
S12.600K |
S12.600S |
S12.601A |
S12.601B |
S12.9XXA |
S12.9XXD |
S12.9XXS |
S14.0XXA |
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 |
S14.108A |
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 |
S14.118A |
S14.118D |
S14.118S |
S14.119A |
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 |
S14.128A |
S14.128D |
S14.128S |
S14.129A |
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 |
S14.151D |
S14.151S |
S14.152A |
S14.152D |
S14.152S |
S14.153A |
S14.153D |
S14.153S |
S14.154A |
S14.154D |
S14.154S |
S14.155A |
S14.155D |
S14.155S |
S14.156A |
S14.156D |
S14.156S |
S14.157A |
S14.157D |
S14.157S |
S14.158A |
S14.158D |
S14.158S |
S14.159A |
S14.159D |
S14.159S |
S14.2XXA |
S14.2XXD |
S14.2XXS |
S14.3XXA |
S14.3XXD |
S14.3XXS |
S14.4XXA |
S14.4XXD |
S14.4XXS |
S14.5XXA |
S14.5XXD |
S14.5XXS |
S14.8XXA |
S14.8XXD |
S14.8XXS |
S14.9XXA |
S14.9XXD |
S14.9XXS |
S22.009A |
S22.009B |
S22.009D |
S22.009G |
S22,009K |
S22.009S |
S22.019A |
S22.019B |
S22.019D |
S22.019G |
S22.019K |
S22.019S |
S22.029A |
S22.029B |
S22.029D |
S22.029G |
S22.029K |
S22.029S |
S22.039A |
S22.039B |
S22.039D |
S22.039G |
S22.039K |
S22.039S |
S22.049A |
S22.049B |
S22.049D |
S22.049G |
S22.049K |
S22.049S |
S22.059A |
S22.059B |
S22.059D |
S22.059G |
S22.059K |
S22.059S |
S22.069A |
S22.069B |
S22.069D |
S22.069G |
S22.069K |
S22.069S |
S22.079A |
S22.079B |
S22.079D |
S22.079G |
S22.079K |
S22.079S |
S22.089A |
S22.089B |
S22.089D |
S22.089G |
S22.089K |
S22.089S |
S24.0XXA |
S24.0XXD |
S24.0XXS |
S24.101A |
S24.101D |
S24.101S |
S24.102A |
S24.102D |
S24.102S |
S24.103A |
S24.103D |
S24.103S |
S24.104A |
S24.104D |
S24.104S |
S24.109A |
S24.109D |
S24.109S |
S24.111A |
S24.111D |
S24.111S |
S24.112A |
S24.112D |
S24.112S |
S24.113A |
S24.113D |
S24.113S |
S24.114A |
S24.114D |
S24.114S |
S24.119A |
S24.119D |
S24.119S |
S24.131A |
S24.131D |
S24.131S |
S24.132A |
S24.132D |
S24.132S |
S24.133A |
S24.133D |
S24.133S |
S24.134A |
S24.134D |
S24.134S |
S24.139A |
S24.139D |
S24.139S |
S24.141A |
S24.141D |
S24.141S |
S24.142A |
S24.142D |
S24.142S |
S24.143A |
S24.143D |
S24.143S |
S24.144A |
S24.144D |
S24.144S |
S24.149A |
S24.149D |
S24.149S |
S24.151A |
S24.151D |
S24.151S |
S24.152A |
S24.152D |
S24.152S |
S24.153A |
S24.153D |
S24.153S |
S24.154A |
S24.154D |
S24.154S |
S24.159A |
S24.159D |
S24.159S |
S24.2XXA |
S24.2XXD |
S24.2XXS |
S24.3XXA |
S24.3XXD |
S24.3XXS |
S24.4XXA |
S24.4XXD |
S24.4XXS |
S24.8XXA |
S24.8XXD |
S24.8XXS |
S24.9XXA |
S24.9XXD |
S24.9XXS |
S32.009A |
S32.009B |
S32.009D |
S32.019A |
S32.019B |
S32.019D |
S32.019G |
S32.019K |
S32.019S |
S32.029A |
S32.029B |
S32.029D |
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S32.2XXA |
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S32.2XXK |
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S34.8XXA |
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S44.21XA |
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S44.30XA |
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S44.40XA |
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S44.90XD |
S44.90XS |
S44.91XA |
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S44.91XS |
S44.92XA |
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S44.92XS |
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S54.8X2A |
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S54.02XA |
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S54.20XA |
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S54.8X2A |
S54.8X2D |
S54.8X2S |
S54.8X9A |
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S54.90XD |
S54.90XS |
S54.91XA |
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S54.91XS |
S54.92XA |
S54.92XD |
S54.92XS |
S64.00XA |
S64.00XD |
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S64.02XA |
S64.02XD |
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S64.11XA |
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S64.12XA |
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S64.21XA |
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S64.21XS |
S64.22XA |
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S64.30XA |
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S64.30XS |
S64.31XA |
S64.31XD |
S64.31XS |
S64.32XA |
S64.32XD |
S64.32XS |
S64.40XA |
S64.40XD |
S64.40XS |
S64.490A |
S64.490D |
S64.490S |
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S64.496S |
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S64.498S |
S64.8X1A |
S64.8X1D |
S64.8X1S |
S64.8X2A |
S64.8X2D |
S64.8X2S |
S64.8X9A |
S64.8X9D |
S64.8X9S |
S64.90XD |
S64.90XS |
S64.91XA |
S64.91XD |
S64.91XS |
S64.92XA |
S64.92XD |
S64.92XS |
S64.494A |
S64.497A |
S74.8X1A |
S74.8X2A |
S74.8X9A |
S74.00XA |
S74.00XD |
S74.00XS |
S74.01XA |
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S74.01XS |
S74.02XA |
S74.02XD |
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S74.10XA |
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S74.11XA |
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S74.12XA |
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S74.12XS |
S74.20XA |
S74.20XD |
S74.20XS |
S74.21XA |
S74.21XD |
S74.21XS |
S74.22XA |
S74.22XD |
S74.22XS |
S74.8X1A |
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S74.8X2A |
S74.8X2D |
S74.8X2S |
S74.8X9A |
S74.8X9D |
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S74.90XA |
S74.90XD |
S74.90XS |
S74.91XA |
S74.91XD |
S74.91XS |
S74.92XA |
S74.92XD |
S74.92XS |
S84.00XA |
S84.00XD |
S84.00XS |
S84.01XA |
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S84.02XA |
S84.02XD |
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S84.12XA |
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S84.20XA |
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S84.20XS |
S84.21XA |
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S84.22XA |
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S84.90XS |
S84.91XA |
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S84.92XA |
S84.92XD |
S84.92XS |
S84.801A |
S84.801D |
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S84.809D |
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S94.8X2A |
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S94.00XS |
S94.01XA |
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S94.02XA |
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S94.10XA |
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S94.20XA |
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S94.20XS |
S94.21XA |
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S94.30XA |
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S94.31XA |
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S94.32XA |
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S94.8X1A |
S94.8X1D |
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S94.8X2A |
S94.8X2D |
S94.8X2S |
S94.8X9A |
S94.8X9D |
S94.8X9S |
S94.90XA |
S94.90XD |
S94.90XS |
S94.91XA |
S94.91XD |
S94.91XS |
S94.92XA |
S94.92XD |
S94.92XS |
S14.104S |
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S14.2XXS |
S14.3XXA |
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S14.3XXS |
S14.4XXA |
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S14.5XXA |
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S14.5XXS |
S14.8XXA |
S14.8XXD |
S14.8XXS |
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S54.31XA |
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S54.32XA |
S54.32XD |
S54.32XS |
S54.8X1A |
S54.8X1D |
S54.8X1S |
S54.8X2A |
S54.8X2D |
S54.8X2S |
S54.8X9A |
S54.8X9D |
S54.8X9S |
S54.90XA |
S54.90XD |
S54.90XS |
S54.91XA |
S54.91XD |
S54.91XS |
S54.92XA |
S54.92XD |
S54.92XS |
S64.00XA |
S64.00XD |
S64.00XS |
S64.01XA |
S64.01XD |
S64.01XS |
S64.02XA |
S64.02XD |
S64.02XS |
S64.10XA |
S64.10XD |
S64.10XS |
S64.11XA |
S64.11XD |
S64.11XS |
S64.12XA |
S64.12XD |
S64.20XA |
S64.20XD |
S64.20XS |
S64.21XA |
S64.21XD |
S64.21XS |
S64.22XA |
S64.22XD |
S64.22XS |
S64.30XA |
S64.30XD |
S64.30XS |
S64.31XA |
S64.31XD |
S64.31XS |
S64.32XA |
S64.32XD |
S64.32XS |
S64.40XA |
S64.40XD |
S64.40XS |
S64.490A |
S64.490D |
S64.490S |
S64.491A |
S64.491D |
S64.491S |
S64.492A |
S64.492D |
S64.492S |
S64.493A |
S64.493D |
S64.493S |
S64.494A |
S64.494D |
S64.494S |
S64.495A |
S64.495D |
S64.495S |
S64.496A |
S64.496D |
S64.496S |
S64.497A |
S64.497D |
S64.497S |
S64.498A |
S64.498D |
S64.498S |
S64.8X1A |
S64.8X1D |
S64.8X1S |
S64.8X2A |
S64.8X2D |
S64.8X2S |
S64.8X9A |
S64.8X9D |
S64.8X9S |
S64.90XD |
S64.90XS |
S64.91XA |
S64.91XD |
S64.91XS |
S64.92XA |
S64.92XD |
S64.92XS |
S64.494A |
S64.497A |
S74.8X1A |
S74.8X2A |
S74.8X9A |
S74.00XA |
S74.00XD |
S74.00XS |
S74.01XA |
S74.01XD |
S74.01XS |
S74.02XA |
S74.02XD |
S74.02XS |
S74.10XA |
S74.10XD |
S74.10XS |
S74.11XA |
S74.11XD |
S74.11XS |
S74.12XA |
S74.12XD |
S74.12XS |
S74.20XA |
S74.20XD |
S74.20XS |
S74.21XA |
S74.21XD |
S74.21XS |
S74.22XA |
S74.22XD |
S74.22XS |
S74.8X1A |
S74.8X1D |
S74.8X1S |
S74.8X2A |
S74.8X2D |
S74.8X2S |
S74.8X9A |
S74.8X9D |
S74.8X9S |
S74.90XA |
S74.90XD |
S74.90XS |
S74.91XA |
S74.91XD |
S74.91XS |
S74.92XA |
S74.92XD |
S74.92XS |
S84.00XA |
S84.00XD |
S84.00XS |
S84.01XA |
S84.01XD |
S84.01XS |
S84.02XA |
S84.02XD |
S84.02XS |
S84.10XA |
S84.10XD |
S84.10XS |
S84.11XA |
S84.11XD |
S84.11XS |
S84.12XA |
S84.12XD |
S84.12XS |
S84.20XA |
S84.20XD |
S84.20XS |
S84.21XA |
S84.21XD |
S84.21XS |
S84.22XA |
S84.22XD |
S84.22XS |
S84.90XA |
S84.90XD |
S84.90XS |
S84.91XA |
S84.91XD |
S84.91XS |
S84.92XA |
S84.92XD |
S84.92XS |
S84.801A |
S84.801D |
S84.801S |
S84.802A |
S84.802D |
S84.802S |
S84.809A |
S84.809D |
S84.809S |
S94.8X1A |
S94.8X2A |
S94.8X9A |
S94.00XA |
S94.00XD |
S94.00XS |
S94.01XA |
S94.01XD |
S94.01XS |
S94.02XA |
S94.02XD |
S94.02XS |
S94.10XA |
S94.10XD |
S94.10XS |
S94.11XA |
S94.11XD |
S94.11XS |
S94.12XA |
S94.12XD |
S94.12XS |
S94.20XA |
S94.20XD |
S94.20XS |
S94.21XA |
S94.21XD |
S94.21XS |
S94.22XA |
S94.22XD |
S94.22XS |
S94.30XA |
S94.30XD |
S94.30XS |
S94.31XA |
S94.31XD |
S94.31XS |
S94.32XA |
S94.32XD |
S94.32XS |
S94.8X1A |
S94.8X1D |
S94.8X1S |
S94.8X2A |
S94.8X2D |
S94.8X2S |
S94.8X9A |
S94.8X9D |
S94.8X9S |
S94.90XA |
S94.90XD |
S94.90XS |
S94.91XA |
S94.91XD |
S94.91XS |
S94.92XA |
S94.92XD |
S94.92XS |
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:
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:
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.
