HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
E-1-062
Topic:
Durable Medical Equipment
Section:
Durable Medical Equipment
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
February 2022
 
 

Durable Medical Equipment (DME) is defined as follows:

  • Equipment must be able to withstand repeated use.
  • It must be primarily and customarily used to serve a medical purpose.
  • It must not be useful to a person in the absence of illness or injury.
  • The equipment must be appropriate for use in the home.

All requirements of the definition must be met before an item can be considered DME.

Policy Position

The following items may be considered medically necessary providing they meet the following criteria:

DME items not meeting the criteria as indicated in this policy are considered not medically necessary

Accessories

  • If the individual owns or is purchasing the equipment.

A4615

A4616

A4640

 

 

 

 


Anti-embolism Stockings

  • Limited to three (3) pairs in a six (6) month period.

A4490

A4495

A4500

A4510

 

 

 


Canes
Quad Canes

  • If individual's condition impairs ambulation.

E0100

E0105

 

 

 

 

 


Commode Chair with Seat Lift Mechanism

  • If the individual is confined to bed or room.
  • If the item is prescribed by a physician for an individual with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases.

E0170

E0171

E0172

 

 

 

 


Commode Chair-on-Wheels

  • If the individual is confined to bed or room confined means that the individual’s condition is such that leaving the room is medically contraindicated.
  • Individuals with poor trunk where there is a safety concern with sitting unsupported and the need for a more physiologic elimination process.

E0163

E0165

E0168

 

 

 

 


Crutches

  • Individual's condition impairs ambulation.

E0110

E0111

E0112

E0113

E0114

E0116

 


Crutch, Underarm, Articulating, Spring Assisted

  • Individuals with Spina Bifida, Cerebral Palsy, or spinal cord injury.

E0117

 

 

 

 

 

 


Crutch Substitute, Lower Leg Platform, with or without Wheels, each

  • If determined to be medically necessary following below the knee injury or surgery.

E0118

 

 

 

 

 

 


Eye Pads/Patches

  • Covered for conditions such as strabismus.

A6410

A6411

A6412

 

 

 

 


Fluidic Breathing Assistor

  • Where there is need for intermittent positive pressure breathing (IPPB) device but oxygen is not required.

E0500

 

 

 

 

 

 


Gait Trainers

  • Individuals who require moderate to maximum support for walking and who are capable of walking with this device.

E8000

E8001

E8002

 

 

 

 


Gloves

  • Refer to Medical Policy E-2, Home Dialysis Equipment for additional information. 

A4927

A4930

 

 

 

 

 


Haberman Feeder

  • Babies with cleft lip and/or cleft palate.

S8265

 

 

 

 

 

 


Heating Pads

Therapeutic Fomentation Device 

  • When a medical review determines individual's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

E0210

E0215

 

 

 

 

 


Heat Lamps

  • When medical review determines individual's medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.

E0200

E0205

 

 

 

 

 


Helmet with Face Guard and Soft Interface Material, Prefabricated

  • When ordered by a physician as medically necessary for individuals with seizure or behavior disorders who are at risk for injury to the head and face.

A8000

A8001

A8002

A8003

 

 

 


Hydrocollator Steam Packs

  • When a medical review determines individual's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.
    • Reimbursement will be made at the amount of an ordinary heating pad. (Refer to Heating Pads)

A9999

E1399

 

 

 

 

 


Injectors and Injection Aid Device

  • Individuals who are unable to use a syringe.

A4210

A4211

 

 

 

 

 


Intermittent Positive Pressure Breathing (IPPB) machine

  • Covered if individual's ability to breathe is severely impaired.

E0500

 

 

 

 

 

 


Jaw Motion Rehabilitation System

  • Must be prescribed by a physician.

E1700

E1701

E1702

 

 

 

 


Lamb's Wool Pads

  • If individual has, or is highly susceptible to, decubitus ulcers; and individual's physician has specified that he or she will be supervising its use in connection with his or her course of treatment.

 E0188

E0189

 

 

 

 

 


Non-elastic Binders for Extremities

Refer to Medical Policy E-9, Non-Custom/Custom-Made Gradient Compression Garments/Stockings/Sleeves, for additional information. 

  • For lymphedema.

A4465

S8430

S8431

 

      


Percussors (conventional)

  • For mobilizing respiratory tract secretions in individuals with pulmonary conditions that limit the ability to expectorate secretions, when patient or operator of the percussor has received appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

E0480

 

 

 

 

 

 


Oscillatory Devices
Flutter
Intrapulmonary Percussive Ventilation System

(Oscillatory positive expiratory pressure device, non-electric, any type, each)

  • Oscillatory devices are alternatives to conventional percussor.
  • Designed to provide self-administered airway clearance.
  • For mobilizing secretions in patients with pulmonary conditions that limit the ability to expectorate secretions.

E0481

E0484

S8185

 

 

 

 


Paraffin Bath Units (portable)

  • The individual has undergone a successful trial period of paraffin therapy when ordered by a physician; and
  • The individual's condition is expected to be relieved by long term use of the modality.

E0235

 

 

 

 

 

 


Paraffin

  • If the Paraffin Bath Unit is covered.

A4265

E0235

 

 

 

 

 


Postural Drainage Boards

  • If individual has a chronic pulmonary condition.

E0606

 

 

 

 

 

 


Rollabout Chairs, Transport Chairs

  • When a medical review determines there is a medical need for this item and it has been prescribed by the individual's physician in lieu of a wheelchair.
  • Limited to those roll about chairs having casters of at least five (5) inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals.

Customized pediatric strollers are covered for a child who is non-ambulatory when either of the following conditions applies:

  • The child requires more support than is available in a standard pediatric wheelchair, or
  • The child is too small to safely use a standard pediatric wheelchair.

E1031

E1035

E1036

E1037

E1038

E1039

 


Safety Rollers

  • For obese individuals; or
  • Those individuals with severe neurological disorders; or
  • Those individuals with restricted use of one hand.

All claims will be referred for medical review/individual consideration.

E1399

 

 

 

 

 

 


Self-Contained Pacemaker Monitor

  • When prescribed by a physician with an individual with a cardiac pacemaker.

E0610

E0615

 

 

 

 

 


Sitz Bath

  • When the individual has an infection or injury of the perineal area and prescribed by the individual's physician as a part of a planned regimen of treatment in the patient's home.

E0160

E0161

E0162

 

 

 

 


Standers

  • For individuals with cerebral palsy, spasticity, multiple sclerosis, and parapareses.
  • For any other condition, individual consideration will be offered.

E0637

E0638

E0641

E0642

 

 

 


Suction Machine

  • If the machine medically required and appropriate for home use without technical or professional supervision.

E0600

E2000

 

 

 

 

 


Surgical Mask         

  • When medically necessary and used in the home.

A4928

 

 

 

 

 

 


Thermometers

  • For chronic renal failure when furnished in conjunction with dialysis services.
  • Must be submitted with modifier AX.

A4931

A4932

 

 

 

 

 


Traction Equipment

  • If individual has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
  • Ambulatory traction device, all types, are considered non-covered

Refer to Medical Policy E-52 Home Cervical Traction Therapy for additional information.

E0870

E0880

E0890

E0900

E0920

E0930

E0941

E0942

E0944

E0945

E0946

E0947

E0948

  


Transfer Board or Device, any type, each

  • When determined to be necessary for the individual to function in the home and/or perform instrumental activities of daily living.

E0705

 

 

 

 

 

 


Trapeze Bars

  • If individual is bed confined and the patient needs a trapeze bar to sit up due to a respiratory condition, to change body position for other medical reasons, or to get in and out of bed.

E0910

E0911

E0912

E0940

 

 

 


Urinals

  • If individual is bed confined.

E0325

E0326

 

 

 

 

 


Vaporizers

  • If individual has a respiratory illness.

E0605

 

 

 

 

 

 


Walkers

  • If the individual has a medical condition impairing ambulation; and
  • There is a potential for ambulation; and
  • There is a need for greater stability and security than provided by a cane or crutches.

E0130

E0135

E0140

E0141

E0143

E0144

E0147

E0148

E0149

 

 

 

 

 


Whirlpool Bath Equipment (standard)

  • If individual is homebound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit; or
  • The individual is not homebound but has such a condition; payment will be limited to the cost of providing the services elsewhere; (e.g., an outpatient department of a participating hospital), if that alternative is less costly.

All claims will be referred for medical review.

E1310

 

 

 

 

 

 


The following is considered not medically necessary:

Continuous Passive Motion (CPM)

  • Continuous Passive Motion (CPM) Devices are considered not medically necessary for all indications.

E0935

E0936

 

 

 

 

 


Non Covered Items

The following items are considered convenience items, comfort items, hygienic equipment or not primarily medical in nature, and are non-covered.

Description

Code

Adjustable high chair

T5001

Alert Systems

A9280

Auto-Tilt Chair

T5001

Backrests        

E1399

Batteries, Replacement 

A4630

Bathtub Lifts, Wirlpool tub, walk-in, portable    

E1300, E0625, K1003

Bathtub/Shower chairs/seats     

E0240, E0245, E0247, E0248

Bath tub Rail, Wall Rail 

E0241, E0242, E0243, E0246

Carafes

E1399

Carrie seats      

T5001

Corner chair     

T5001

Ear Plugs (standard or custom-made)   

E1399

Electric Adaptors (for car, truck, etc.)    

E1399

Elevators         

E1399

Enema/Enema Bags/Enema tubes    

A4458, A4459, K1013

Enuresis (Bed Wetting) Alarm    

S8270

Exercise Equipment, Exercycle 

A9300

Feeder seats    

T5001

Floor sitters     

T5001

Grab Bars                    

E0241, E0242, E0243, E0246    

Heavy Cast Socks-6     

E1399

Hot Water Bottle, ice cap or collar, heat and/or cold wrap, any type (includes ice pack) 

A9273

Hygienic equipment                  

A9286

Hygienic supply           

A9286

Light Cast Sock-6         

E1399

Linen, nonallergenic      

E1399

Lumbar Roll     

E0190

Lumex Ortho-Biotic High Back Rockers 

E1399

Lumex Ortho-Biotic Recliners    

E1399

Massage Chair/Robotic Chair    

E1399

Massage Devices         

E1399

Massage Mattress        

E1399

Massage Table 

E1399

Mileage

E1399

Mobile Monomatic Sanitation System    

E1399

Niagara Massage Pillow

E1399

Niagara Thermo-Cyclopad         

E1399

Positioning cushion/pillow/wedge, any shape or size

E0190

Positioning Support System     

T5001

Posture support chair   

T5001

Raised Toilet Seats      

E0244

Reaching/Grabbing device, any type, any length, each    

A9281

Safety car seats           

E1399

Sauna Baths    

E1399

Silverware/Utensils       

E1399

Standard feeder seats  

T5001

Standard high chairs     

T5001

Telephone Arms           

E1399

Toilet Seats      

E1399

Treadmill Exerciser       

A9300

Tub rail attachment       

E0246

Tub Stool or Bench      

E0240, E0245, E0247, E0248

Versa Form chairs        

T5001

Zero gravity chair         

E1399

 

The following items are considered environmental control equipment, and are non-covered.

Description

Code

Air Cleaners

E1399

Air Conditioners           

E1399

Dehumidifiers

E1399

Environmental control equipment

E1399

Heating and Cooling Plants

E1399

Humidifiers

E1399

Portable Room Heaters

E1399

 

The following items are considered educational equipment; and are not primarily medical in nature and are non-covered.

Description

Code

Braille Teaching Texts

E1399

Communic-Aid

E1902

Communicator

E1902

 

The following items are considered inappropriate for home use or physician instruments or institutional equipment and are non-covered.

Description

Code

Esophageal Dilator       

E1399

American Bidet Toilet Seat        

E1399

Aquamatic K-Thermia

E0217, E0236, E0249

Diathermy Machines, Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories    

E0761, K1004, K1036

Hydrocollator Heating Unit        

E0225, E0239

Intermittent Traction Unit           

E1399

Paraffin Bath Units – non portable         

E1399

Parallel Bars     

E1399

Translift Chair   

E1399

 

The following items are considered non-reusable disposable supplies and are non-covered. 

Description

Code

Disposable Sheets and Bags    

E1399

Delivery, Setup and Service A9901 is non-covered as this is included in the service.

Telephone Alert Systems, E1399 are considered emergency communications systems and do not serve a diagnostic or therapeutic purpose and are therefore non-covered. 

Related Policies

Refer to Medical Policy Z-7 Electrical Nerve Stimulation for additional information.

Refer to Medical Policy E-32 Nebulizers for additional information.

Refer to Medical Policy E-52 Home Cervical Traction Therapy for additional information.

Refer to Medical Policy E-9 Non-Custom/Custom-Made Gradient Compression Garments/Stockings/Sleeves for additional information.

Refer to Medical Policy E-2 Home Dialysis Equipment and Supplies for additional information. 

Refer to Medical Policy E-12 Beds- Accessories and Related Items for additional information.

Refer to Medical Policy O-27, Urological Supplies, for additional information.

Refer to Reimbursement Policy-070, Continuous Rental of Life Sustaining DME, for additional information.


Diagnosis Codes for Procedure Code E0117

G80.0

G80.1

G80.2

G80.4

G80.8

G80.9

G83.5

G83.81

G83.82

G83.83

G83.84

G83.89

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q07.00

Q07.01

Q07.02

Q07.03

S14.0XXA

S14.0XXD

S14.0XXS

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

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

S34.01XA

S34.01XD

S34.01XS

S34.02XA

S34.02XD

S34.02XS

S34.101A

S34.101D

S34.101S

S34.102A

S34.102D

S34.102S

S34.103A

S34.103D

S34.103S

S34.104A

S34.104D

S34.104S

S34.105A

S34.105D

S34.105S

S34.109A

S34.109D

S34.109S

S34.111A

S34.111D

S34.111S

S34.112A

S34.112D

S34.112S

S34.113A

S34.113D

S34.113S

S34.114A

S34.114D

S34.114S

S34.115A

S34.115D

S34.115S

S34.119A

S34.119D

S34.119S

S34.121A

S34.121D

S34.121S

S34.122A

S34.122D

S34.122S

S34.123A

S34.123D

S34.123S

S34.124A

S34.124D

S34.124S

S34.125A

S34.125D

S34.125S

S34.129A

S34.129D

S34.129S

S34.131A

S34.131D

S34.131S

S34.132A

S34.132D

S34.132S

S34.139A

S34.139D

S34.139S

S34.3XXA

S34.3XXD

S34.3XXS

 

 

 

Diagnosis Codes for Procedure Codes A6410, A6411, A6412

H49.00

H49.01

H49.02

H49.03

H49.10

H49.11

H49.12

H49.13

H49.20

H49.21

H49.22

H49.23

H49.30

H49.31

H49.32

H49.33

H49.40

H49.41

H49.42

H49.43

H49.881

H49.882

H49.883

H49.889

H49.9

H50.00

H50.011

H50.012

H50.021

H50.022

H50.031

H50.032

H50.041

H50.042

H50.05

H50.06

H50.07

H50.08

H50.10

H50.111

H50.112

H50.121

H50.122

H50.131

H50.132

H50.141

H50.142

H50.15

H50.16

H50.17

H50.18

H50.60

H50.611

H50.612

H50.621

H50.622

H50.629

H50.631

H50.632

H50.639

H50.641

H50.642

H50.649

H50.651

H50.652

H50.659

H50.661

H50.662

H50.669

H50.671

H50.672

H50.679

H50.681

H50.682

H50.689

H50.69

H50.811

H50.812

H50.89

 

 

 

 

 

 

Diagnosis Codes for Procedure Code S8265

K08.8

M26.79

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

 

 

 

 

Diagnosis Codes for Procedure Code A4465, S8430, S8431

I89.0

I89.1

I89.8

I89.9

I97.2

Q82.0

 

Diagnosis Codes for Procedure Code E0637, E0638, E0641, E0642

G04.1

G35

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G82.20

G82.21

G82.22

G83.9

R25.0

R25.1

R25.2

R25.3

R25.8

R25.9

 

 

 

Diagnosis Codes for Procedure Code A4931, A4932

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

N18.1

N18.2

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

N18.9

N19

N99.0

 

 

 

 

 

Diagnosis Codes for Procedure Code E0480, E0481, E0484, S8185

E84.0

E84.8

E84.9

E84.11

E84.19

J41.0

J41.1

J41.8

J42

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

Q33.4

Z48.24

Z48.280

Z94.2

Z94.3

 

 

 

 


Place of Service: Outpatient

The use of DME 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.

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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




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.