HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
E-35-018
Topic:
Ultrasound Osteogenesis Stimulator
Section:
Durable Medical Equipment
Effective Date:
December 10, 2018
Issued Date:
December 10, 2018
Last Revision Date:
October 2018
Annual Review:
October 2018
 
 

An ultrasonic osteogenesis stimulator is a noninvasive device that emits low intensity, pulsed ultrasound. The ultrasound signal is applied to the skin surface at the fracture location via ultrasound conductive coupling gel in order to stimulate fracture healing.

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

An ultrasonic osteogenesis stimulator is covered only if All of the following criteria are met:

  • Nonunion of a fracture (at least three (3) months have passed since the date of the fracture); and
  • The fracture is not of the skull or vertebrae; and
  • Serial radiographs have confirmed that no progressive signs of healing have occurred; and
  • The fracture gap is 1 cm or less; and
  • The patient can be adequately immobilized and is able to maintain a non-weight bearing status.
E0760



Fresh Closed Fractures

Low-intensity ultrasound accelerated fracture healing systems may be considered medically necessary and, therefore, covered as an adjunct to conventional management (i.e., closed reduction and cast immobilization) for the treatment of fresh (up to fourteen (14) days after the fracture occurs), closed fractures of a skeletally mature individual, who is determined to be at high risk for delayed fracture healing or nonunion fractures, that includes having at least ANY of the following indications: a comorbidity OR location of fracture:

The individual has ANY of the following comorbidities:

  • Diagnosis of alcoholism; or
  • Current tobacco use; or
  • Diagnosis of diabetes; or
  • Current use of prescribed steroid; or
  • Diagnosis of osteoporosis; or
  • Diagnosis of renal disease; or
  • Current use of prescribed anticoagulation medications.

    OR

The individual has ANY of the following fracture locations:

  • Fracture of metatarsal, including Jones fracture (5th metatarsal); or
  • Navicular bone fracture of the wrist (also known as the scaphoid); or
  • Fractures associated with extensive soft tissue or vascular damage.

 It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in these situations.

E0760



If the above criteria are not met, an ultrasonic osteogenesis stimulator will be denied as not medically necessary. This includes, but is not limited to treatment of ANY of the following:

  • As an adjunct to (i.e., at the time of or immediately after) bunionectomy procedures (When such surgery results in nonunion the medically necessary criteria above may apply); or
  • As an adjunct to (i.e., at the time of or immediately after) distraction osteogenesis procedures for any indication (e.g., limb lengthening, nonunion, or tibial defects); or
  • Axial skeleton fractures, including the skull and vertebrae; or
  • Congenital pseudoarthrosis; or
  • Delayed fracture unions; or
  • Fresh fractures that are Open Grade II or III, or require surgical intervention (with or without internal fixation), or are otherwise too unstable for closed reduction/; or
  • Patellar tendinopathy; or
  • Pathological fractures due to bone pathology or tumor/malignancy; or
  • Stress fractures; or
  • Used with other nonivasive osteogenesis stimulators.

 E0760




An ultrasonic osteogenesis stimulator will be denied as not medically necessary if it is used with other noninvasive osteogenesis stimulators.

E0747

E0760

 

 

 

 

 




Related Policies

 

Refer to medical policy S-89, Electrical Osteogenesis Bone Stimulation, for additional information.

 


Covered Diagnosis Codes for Procedure Codes 20979, A4559, and E0760

E10.9

E10.65

E11.9

E11.65

E13.9

F10.20

F17.200

F17.201

F17.210

F17.211

F17.220

F17.221

F17.290

F17.291

M80.00XK

M80.08XK

M80.80XK

M80.88XK

M80.011K

M80.012K

M80.019K

M80.021K

M80.022K

M80.029K

M80.031K

M80.032K

M80.039K

M80.041K

M80.042K

M80.049K

M80.051K

M80.052K

M80.059K

M80.061K

M80.062K

M80.069K

M80.071K

M80.072K

M80.079K

M80.811K

M80.812K

M80.819K

M80.821K

M80.822K

M80.829K

M80.831K

M80.832K

M80.839K

M80.841K

M80.842K

M80.849K

M80.851K

M80.852K

M80.859K

M80.861K

M80.862K

M80.869K

M80.871K

M80.872K

M80.879K

M81.0

M81.6

M81.8

M84.30XK

M84.38XK

M84.40XK

M84.48XK

M84.50XK

M84.58XK

M84.60XK

M84.68XK

M84.311K

M84.312K

M84.319K

M84.321K

M84.322K

M84.329K

M84.331K

M84.332K

M84.333K

M84.334K

M84.339K

M84.341K

M84.342K

M84.343K

M84.344K

M84.345K

M84.346K

M84.350K

M84.351K

M84.352K

M84.353K

M84.359K

M84.361K

M84.362K

M84.363K

M84.364K

M84.369K

M84.371K

M84.372K

M84.373K

M84.374K

M84.375K

M84.376K

M84.377K

M84.378K

M84.379K

M84.411K

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M84.422K

M84.429K

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M84.441K

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M84.443K

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M84.445K

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M84.451K

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M84.453K

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M84.459K

M84.461K

M84.462K

M84.463K

M84.464K

M84.469K

M84.471K

M84.472K

M84.473K

M84.474K

M84.475K

M84.476K

M84.477K

M84.478K

M84.479K

M84.511K

M84.512K

M84.519K

M84.521K

M84.522K

M84.529K

M84.531K

M84.532K

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M84.539K

M84.541K

M84.542K

M84.549K

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M84.551K

M84.552K

M84.553K

M84.559K

M84.561K

M84.562K

M84.563K

M84.564K

M84.569K

M84.571K

M84.572K

M84.573K

M84.574K

M84.575K

M84.576K

M84.611K

M84.612K

M84.619K

M84.621K

M84.622K

M84.629K

M84.631K

M84.632K

M84.633K

M84.634K

M84.639K

M84.641K

M84.642K

M84.649K

M84.650K

M84.651K

M84.652K

M84.653K

M84.659K

M84.661K

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M84.664K

M84.669K

M84.671K

M84.672K

M84.673K

M84.674K

M84.675K

M84.676K

M84.750G

M84.750K

M84.750P

M84.754G

M84.754K

M84.754P

M84.755G

M84.755K

M84.755P

M84.756G

M84.756K

M84.756P

M84.757G

M84.757K

M84.757P

M84.758G

M84.758K

M84.758P

M84.759G

M84.759K

M84.759P

N18.1

N18.2

N18.3

N18.4

N18.5

N18.6

N18.9

S02.0XXK

S02.2XXK

S02.5XXK

S02.19XK

S02.42XK

S02.63XK

S02.66XK

S02.69XK

S02.80XB

S02.80XG

S02.80XK

S02.80XS

S02.81XA

S02.81XB

S02.81XG

S02.81XK

S02.81XS

S02.82XA

S02.82XB

S02.82XG

S02.82XK

S02.91XK

S02.92XK

S02.110K

S02.111K

S02.112K

S02.113K

S02.118K

S02.119K

S02.400K

S02.401K

S02.402K

S02.411K

S02.412K

S02.413K

S02.600K

S02.609K

S02.610B

S02.610G

S02.610K

S02.611B

S02.611G

S02.611K

S02.612B

S02.612G

S02.612K

S02.620B

S02.620G

S02.620K

S02.621B

S02.621G

S02.621K

S02.622B

S02.622G

S02.622K

S02.630B

S02.630G

S02.630K

S02.631B

S02.631G

S02.632B

S02.632G

S02.632K

S02.640B

S02.640G

S02.640K

S02.641B

S02.641G

S02.641K

S02.642B

S02.642G

S02.642K

S02.650B

S02.650G

S02.650K

S02.651B

S02.651G

S02.651K

S02.652B

S02.652G

S02.652K

S02.670B

S02.670G

S02.670K

S02.671B

S02.671G

S02.671K

S02.672B

S02.672G

S02.672K

S02.672S

S12.01XK

S12.02XK

S12.14XK

S12.24XK

S12.34XK

S12.44XK

S12.54XK

S12.64XK

S12.000K

S12.001K

S12.030K

S12.031K

S12.040K

S12.041K

S12.090K

S12.091K

S12.100K

S12.101K

S12.110K

S12.111K

S12.112K

S12.120K

S12.121K

S12.130K

S12.131K

S12.150K

S12.151K

S12.190K

S12.191K

S12.200K

S12.201K

S12.230K

S12.231K

S12.250K

S12.251K

S12.290K

S12.291K

S12.300K

S12.301K

S12.330K

S12.331K

S12.350K

S12.351K

S12.390K

S12.391K

S12.400K

S12.401K

S12.430K

S12.431K

S12.450K

S12.451K

S12.490K

S12.491K

S12.500K

S12.501K

S12.530K

S12.531K

S12.550K

S12.551K

S12.590K

S12.591K

S12.600K

S12.601K

S12.630K

S12.631K

S12.650K

S12.651K

S12.690K

S12.691K

S22.5XXK

S22.9XXK

S22.20XK

S22.21XK

S22.22XK

S22.23XK

S22.24XK

S22.31XK

S22.32XK

S22.39XK

S22.41XK

S22.42XK

S22.43XK

S22.49XK

S22.000K

S22.001K

S22.002K

S22.008K

S22.009K

S22.010K

S22.011K

S22.012K

S22.018K

S22.019K

S22.020K

S22.021K

S22.022K

S22.028K

S22.029K

S22.030K

S22.031K

S22.032K

S22.038K

S22.039K

S22.040K

S22.041K

S22.042K

S22.048K

S22.049K

S22.050K

S22.051K

S22.052K

S22.058K

S22.059K

S22.060K

S22.061K

S22.062K

S22.068K

S22.069K

S22.070K

S22.071K

S22.072K

S22.078K

S22.079K

S22.080K

S22.081K

S22.082K

S22.088K

S22.089K

S32.2XXK

S32.9XXK

S32.10XK

S32.14XK

S32.15XK

S32.16XK

S32.17XK

S32.19XK

S32.82XK

S32.89XK

S32.000K

S32.001K

S32.002K

S32.008K

S32.009K

S32.010K

S32.011K

S32.012K

S32.018K

S32.019K

S32.020K

S32.021K

S32.022K

S32.028K

S32.029K

S32.030K

S32.031K

S32.032K

S32.038K

S32.039K

S32.040K

S32.041K

S32.042K

S32.048K

S32.049K

S32.050K

S32.051K

S32.052K

S32.058K

S32.059K

S32.110K

S32.111K

S32.112K

S32.119K

S32.120K

S32.121K

S32.122K

S32.129K

S32.130K

S32.131K

S32.132K

S32.139K

S32.301K

S32.302K

S32.309K

S32.311K

S32.312K

S32.313K

S32.314K

S32.315K

S32.316K

S32.391K

S32.392K

S32.399K

S32.401K

S32.402K

S32.409K

S32.411K

S32.412K

S32.413K

S32.414K

S32.415K

S32.416K

S32.421K

S32.422K

S32.423K

S32.424K

S32.425K

S32.426K

S32.431K

S32.432K

S32.433K

S32.434K

S32.435K

S32.436K

S32.441K

S32.442K

S32.443K

S32.444K

S32.445K

S32.446K

S32.451K

S32.452K

S32.453K

S32.454K

S32.455K

S32.456K

S32.461K

S32.462K

S32.463K

S32.464K

S32.465K

S32.466K

S32.471K

S32.472K

S32.473K

S32.474K

S32.475K

S32.476K

S32.481K

S32.482K

S32.483K

S32.484K

S32.485K

S32.486K

S32.491K

S32.492K

S32.499K

S32.501K

S32.502K

S32.509K

S32.511K

S32.512K

S32.519K

S32.591K

S32.592K

S32.599K

S32.601K

S32.602K

S32.609K

S32.611K

S32.612K

S32.613K

S32.614K

S32.615K

S32.616K

S32.691K

S32.692K

S32.699K

S32.810K

S32.811K

S42.90XK

S42.91XK

S42.92XK

S42.001K

S42.002K

S42.009K

S42.011K

S42.012K

S42.013K

S42.014K

S42.015K

S42.016K

S42.017K

S42.018K

S42.019K

S42.021K

S42.022K

S42.023K

S42.024K

S42.025K

S42.026K

S42.031K

S42.032K

S42.033K

S42.034K

S42.035K

S42.036K

S42.101K

S42.102K

S42.109K

S42.111K

S42.112K

S42.113K

S42.114K

S42.115K

S42.116K

S42.121K

S42.122K

S42.123K

S42.124K

S42.125K

S42.126K

S42.131K

S42.132K

S42.133K

S42.134K

S42.135K

S42.136K

S42.141K

S42.142K

S42.143K

S42.144K

S42.145K

S42.146K

S42.151K

S42.152K

S42.153K

S42.154K

S42.155K

S42.156K

S42.191K

S42.192K

S42.199K

S42.201K

S42.202K

S42.209K

S42.211K

S42.212K

S42.213K

S42.214K

S42.215K

S42.216K

S42.221K

S42.222K

S42.223K

S42.224K

S42.225K

S42.226K

S42.231K

S42.232K

S42.239K

S42.241K

S42.242K

S42.249K

S42.251K

S42.252K

S42.253K

S42.254K

S42.255K

S42.256K

S42.261K

S42.262K

S42.263K

S42.264K

S42.265K

S42.266K

S42.271K

S42.272K

S42.279K

S42.291K

S42.292K

S42.293K

S42.294K

S42.295K

S42.296K

S42.301K

S42.302K

S42.309K

S42.311K

S42.312K

S42.319K

S42.321K

S42.322K

S42.323K

S42.324K

S42.325K

S42.326K

S42.331K

S42.332K

S42.333K

S42.334K

S42.335K

S42.336K

S42.341K

S42.342K

S42.343K

S42.344K

S42.345K

S42.346K

S42.351K

S42.352K

S42.353K

S42.354K

S42.355K

S42.356K

S42.361K

S42.362K

S42.363K

S42.364K

S42.365K

S42.366K

S42.391K

S42.392K

S42.399K

S42.401K

S42.402K

S42.409K

S42.411K

S42.412K

S42.413K

S42.414K

S42.415K

S42.416K

S42.421K

S42.422K

S42.423K

S42.424K

S42.425K

S42.426K

S42.431K

S42.432K

S42.433K

S42.434K

S42.435K

S42.436K

S42.441K

S42.442K

S42.443K

S42.444K

S42.445K

S42.446K

S42.447K

S42.448K

S42.449K

S42.451K

S42.452K

S42.453K

S42.454K

S42.455K

S42.456K

S42.461K

S42.462K

S42.463K

S42.464K

S42.465K

S42.466K

S42.471K

S42.472K

S42.473K

S42.474K

S42.475K

S42.476K

S42.481K

S42.482K

S42.489K

S42.491K

S42.492K

S42.493K

S42.494K

S42.495K

S42.496K

S49.001K

S49.002K

S49.009K

S49.011K

S49.012K

S49.019K

S49.021K

S49.022K

S49.029K

S49.031K

S49.032K

S49.039K

S49.041K

S49.042K

S49.049K

S49.091K

S49.092K

S49.099K

S49.101K

S49.102K

S49.109K

S49.111K

S49.112K

S49.119K

S49.121K

S49.122K

S49.129K

S49.131K

S49.132K

S49.139K

S49.141K

S49.142K

S49.149K

S49.191K

S49.192K

S49.199K

S52.90XK

S52.90XM

S52.90XN

S52.91XK

S52.91XM

S52.91XN

S52.92XK

S52.92XM

S52.92XN

S52.001K

S52.001M

S52.001N

S52.002K

S52.002M

S52.002N

S52.009K

S52.009M

S52.009N

S52.011K

S52.012K

S52.019K

S52.021K

S52.021M

S52.021N

S52.022K

S52.022M

S52.022N

S52.023K

S52.023M

S52.023N

S52.024K

S52.024M

S52.024N

S52.025K

S52.025M

S52.025N

S52.026K

S52.026M

S52.026N

S52.031K

S52.031M

S52.031N

S52.032K

S52.032M

S52.032N

S52.033K

S52.033M

S52.033N

S52.034K

S52.034M

S52.034N

S52.035K

S52.035M

S52.035N

S52.036K

S52.036M

S52.036N

S52.041K

S52.041M

S52.041N

S52.042K

S52.042M

S52.042N

S52.043K

S52.043M

S52.043N

S52.044K

S52.044M

S52.044N

S52.045K

S52.045M

S52.045N

S52.046K

S52.046M

S52.046N

S52.091K

S52.091M

S52.091N

S52.092K

S52.092M

S52.092N

S52.099K

S52.099M

S52.099N

S52.101K

S52.101M

S52.101N

S52.102K

S52.102M

S52.102N

S52.109K

S52.109M

S52.109N

S52.111K

S52.112K

S52.119K

S52.121K

S52.121M

S52.121N

S52.122K

S52.122M

S52.122N

S52.123K

S52.123M

S52.123N

S52.124K

S52.124M

S52.124N

S52.125K

S52.125M

S52.125N

S52.126K

S52.126M

S52.126N

S52.131K

S52.131M

S52.131N

S52.132K

S52.132M

S52.132N

S52.133K

S52.133M

S52.133N

S52.134K

S52.134M

S52.134N

S52.135K

S52.135M

S52.135N

S52.136K

S52.136M

S52.136N

S52.181K

S52.181M

S52.181N

S52.182K

S52.182M

S52.182N

S52.189K

S52.189M

S52.189N

S52.201K

S52.201M

S52.201N

S52.202K

S52.202M

S52.202N

S52.209K

S52.209M

S52.209N

S52.211K

S52.212K

S52.219K

S52.221K

S52.221M

S52.221N

S52.222K

S52.222M

S52.222N

S52.223K

S52.223M

S52.223N

S52.224K

S52.224M

S52.224N

S52.225K

S52.225M

S52.225N

S52.226K

S52.226M

S52.226N

S52.231K

S52.231M

S52.231N

S52.232K

S52.232M

S52.232N

S52.233K

S52.233M

S52.233N

S52.234K

S52.234M

S52.234N

S52.235K

S52.235M

S52.235N

S52.236K

S52.236M

S52.236N

S52.241K

S52.241M

S52.241N

S52.242K

S52.242M

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S59.029K

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S59.102K

S59.109K

S59.111K

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S59.119K

S59.121K

S59.122K

S59.129K

S59.131K

S59.132K

S59.139K

S59.141K

S59.142K

S59.149K

S59.191K

S59.192K

S59.199K

S59.201K

S59.202K

S59.209K

S59.211K

S59.212K

S59.219K

S59.221K

S59.222K

S59.229K

S59.231K

S59.232K

S59.239K

S59.241K

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S62.113K

S62.114K

S62.115K

S62.116K

S62.121K

S62.122K

S62.123K

S62.124K

S62.125K

S62.126K

S62.131K

S62.132K

S62.133K

S62.134K

S62.135K

S62.136K

S62.141K

S62.142K

S62.143K

S62.144K

S62.145K

S62.146K

S62.151K

S62.152K

S62.153K

S62.154K

S62.155K

S62.156K

S62.161K

S62.162K

S62.163K

S62.164K

S62.165K

S62.166K

S62.171K

S62.172K

S62.173K

S62.174K

S62.175K

S62.176K

S62.181K

S62.182K

S62.183K

S62.184K

S62.185K

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S62.212K

S62.213K

S62.221K

S62.222K

S62.223K

S62.224K

S62.225K

S62.226K

S62.231K

S62.232K

S62.233K

S62.234K

S62.235K

S62.236K

S62.241K

S62.242K

S62.243K

S62.244K

S62.245K

S62.246K

S62.251K

S62.252K

S62.253K

S62.254K

S62.255K

S62.256K

S62.291K

S62.292K

S62.299K

S62.300K

S62.301K

S62.302K

S62.303K

S62.304K

S62.305K

S62.306K

S62.307K

S62.308K

S62.309K

S62.310K

S62.311K

S62.312K

S62.313K

S62.314K

S62.315K

S62.316K

S62.317K

S62.318K

S62.319K

S62.320K

S62.321K

S62.322K

S62.323K

S62.324K

S62.325K

S62.326K

S62.327K

S62.328K

S62.329K

S62.330K

S62.331K

S62.332K

S62.333K

S62.334K

S62.335K

S62.336K

S62.337K

S62.338K

S62.339K

S62.340K

S62.341K

S62.342K

S62.343K

S62.344K

S62.345K

S62.346K

S62.347K

S62.348K

S62.349K

S62.350K

S62.351K

S62.352K

S62.353K

S62.354K

S62.355K

S62.356K

S62.357K

S62.358K

S62.359K

S62.360K

S62.361K

S62.362K

S62.363K

S62.364K

S62.365K

S62.366K

S62.367K

S62.368K

S62.369K

S62.390K

S62.391K

S62.392K

S62.393K

S62.394K

S62.395K

S62.396K

S62.397K

S62.398K

S62.399K

S62.501K

S62.502K

S62.509K

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S62.513K

S62.514K

S62.515K

S62.516K

S62.521K

S62.522K

S62.523K

S62.524K

S62.525K

S62.526K

S62.600K

S62.601K

S62.602K

S62.603K

S62.604K

S62.605K

S62.606K

S62.607K

S62.608K

S62.609K

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S62.612K

S62.613K

S62.614K

S62.615K

S62.616K

S62.617K

S62.618K

S62.619K

S62.620K

S62.621K

S62.622K

S62.623K

S62.624K

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S62.626K

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S62.628K

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S62.630K

S62.631K

S62.632K

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S62.634K

S62.635K

S62.636K

S62.637K

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S62.640K

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S79.121K

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S79.129K

S79.131K

S79.132K

S79.139K

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S79.149K

S79.191K

S79.192K

S79.199K

S82.51XK

S82.51XM

S82.51XN

S82.52XK

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S82.52XN

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S82.53XM

S82.53XN

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S82.54XM

S82.54XN

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S82.55XN

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S82.56XN

S82.61XK

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S82.61XN

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S82.62XN

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S82.63XM

S82.63XN

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S82.64XM

S82.64XN

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S82.65XM

S82.65XN

S82.66XK

S82.66XM

S82.66XN

S82.90XK

S82.90XM

S82.90XN

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S82.91XM

S82.91XN

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S82.92XM

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S82.001K

S82.001M

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S82.161K

S82.162K

S82.169K

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S82.261K

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S82.291K

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S82.292N

S82.299K

S82.299M

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S82.301N

S82.302K

S82.302M

S82.302N

S82.309K

S82.309M

S82.309N

S82.311K

S82.312K

S82.319K

S82.391K

S82.391M

S82.391N

S82.392K

S82.392M

S82.392N

S82.399K

S82.399M

S82.399N

S82.401K

S82.401M

S82.401N

S82.402K

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S82.402N

S82.409K

S82.409M

S82.409N

S82.421K

S82.421M

S82.421N

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S82.422M

S82.422N

S82.423K

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S82.423N

S82.424K

S82.424M

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S82.425K

S82.425M

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S82.426M

S82.426N

S82.431K

S82.431M

S82.431N

S82.432K

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S82.433K

S82.433M

S82.433N

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S82.441K

S82.441M

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S82.443K

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S82.451K

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S82.455K

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S82.455N

S82.456K

S82.456M

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S82.461K

S82.461M

S82.461N

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S82.462M

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S82.463K

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S82.465K

S82.465M

S82.465N

S82.466K

S82.466M

S82.466N

S82.491K

S82.491M

S82.491N

S82.492K

S82.492M

S82.492N

S82.499K

S82.499M

S82.499N

S82.811K

S82.812K

S82.819K

S82.821K

S82.822K

S82.829K

S82.831K

S82.831M

S82.831N

S82.832K

S82.832M

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S82.839K

S82.839M

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S82.841K

S82.841M

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S82.866K

S82.866M

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S82.874M

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S82.875M

S82.875N

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S82.891K

S82.891M

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S82.892M

S82.892N

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S82.899M

S82.899N

S89.001K

S89.002K

S89.009K

S89.011K

S89.012K

S89.019K

S89.021K

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S89.029K

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S89.039K

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S89.049K

S89.091K

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S89.109K

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S89.129K

S89.131K

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S89.139K

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S89.149K

S89.191K

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S89.291K

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S89.299K

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S89.319K

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S89.329K

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S92.001K

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S92.301A

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S92.919K

Z92.240

Z92.241

 

 

 

 

 



Place of Service: Outpatient

Use of an Ultrasonic Osteogenesis Stimulator 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


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.



Links






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.