E-35-018

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	M84.412K	M84.419K	M84.421K	M84.422K
M84.429K	M84.431K	M84.432K	M84.433K	M84.434K	M84.439K	M84.441K
M84.442K	M84.443K	M84.444K	M84.445K	M84.446K	M84.451K	M84.452K
M84.453K	M84.454K	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	M84.533K	M84.534K	M84.539K
M84.541K	M84.542K	M84.549K	M84.550K	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	M84.662K	M84.663K	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
S52.242N	S52.243K	S52.243M	S52.243N	S52.244K	S52.244M	S52.244N
S52.245K	S52.245M	S52.245N	S52.246K	S52.246M	S52.246N	S52.251K
S52.251M	S52.251N	S52.252K	S52.252M	S52.252N	S52.253K	S52.253M
S52.253N	S52.254K	S52.254M	S52.254N	S52.255K	S52.255M	S52.255N
S52.256K	S52.256M	S52.256N	S52.261K	S52.261M	S52.261N	S52.262K
S52.262M	S52.262N	S52.263K	S52.263M	S52.263N	S52.264K	S52.264M
S52.264N	S52.265K	S52.265M	S52.265N	S52.266K	S52.266M	S52.266N
S52.271K	S52.271M	S52.271N	S52.272K	S52.272M	S52.272N	S52.279K
S52.279M	S52.279N	S52.281K	S52.281M	S52.281N	S52.282K	S52.282M
S52.282N	S52.283K	S52.283M	S52.283N	S52.291K	S52.291M	S52.291N
S52.292K	S52.292M	S52.292N	S52.299K	S52.299M	S52.299N	S52.301K
S52.301M	S52.301N	S52.302K	S52.302M	S52.302N	S52.309K	S52.309M
S52.309N	S52.311K	S52.312K	S52.319K	S52.321K	S52.321M	S52.321N
S52.322K	S52.322M	S52.322N	S52.323K	S52.323M	S52.323N	S52.324K
S52.324M	S52.324N	S52.325K	S52.325M	S52.325N	S52.326K	S52.326M
S52.326N	S52.331K	S52.331M	S52.331N	S52.332K	S52.332M	S52.332N
S52.333K	S52.333M	S52.333N	S52.334K	S52.334M	S52.334N	S52.335K
S52.335M	S52.335N	S52.336K	S52.336M	S52.336N	S52.341K	S52.341M
S52.341N	S52.342K	S52.342M	S52.342N	S52.343K	S52.343M	S52.343N
S52.344K	S52.344M	S52.344N	S52.345K	S52.345M	S52.345N	S52.346K
S52.346M	S52.346N	S52.351K	S52.351M	S52.351N	S52.352K	S52.352M
S52.352N	S52.353K	S52.353M	S52.353N	S52.354K	S52.354M	S52.354N
S52.355K	S52.355M	S52.355N	S52.356K	S52.356M	S52.356N	S52.361K
S52.361M	S52.361N	S52.362K	S52.362M	S52.362N	S52.363K	S52.363M
S52.363N	S52.364K	S52.364M	S52.364N	S52.365K	S52.365M	S52.365N
S52.366K	S52.366M	S52.366N	S52.371K	S52.371M	S52.371N	S52.372K
S52.372M	S52.372N	S52.379K	S52.379M	S52.379N	S52.381K	S52.381M
S52.381N	S52.382K	S52.382M	S52.382N	S52.389K	S52.389M	S52.389N
S52.391K	S52.391M	S52.391N	S52.392K	S52.392M	S52.392N	S52.399K
S52.399M	S52.399N	S52.501K	S52.501M	S52.501N	S52.502K	S52.502M
S52.502N	S52.509K	S52.509M	S52.509N	S52.511K	S52.511M	S52.511N
S52.512K	S52.512M	S52.512N	S52.513K	S52.513M	S52.513N	S52.514K
S52.514M	S52.514N	S52.515K	S52.515M	S52.515N	S52.516K	S52.516M
S52.516N	S52.521K	S52.522K	S52.529K	S52.531K	S52.531M	S52.531N
S52.532K	S52.532M	S52.532N	S52.539K	S52.539M	S52.539N	S52.541K
S52.541M	S52.541N	S52.542K	S52.542M	S52.542N	S52.549K	S52.549M
S52.549N	S52.551K	S52.551M	S52.551N	S52.552K	S52.552M	S52.552N
S52.559K	S52.559M	S52.559N	S52.561K	S52.561M	S52.561N	S52.562K
S52.562M	S52.562N	S52.569K	S52.569M	S52.569N	S52.571K	S52.571M
S52.571N	S52.572K	S52.572M	S52.572N	S52.579K	S52.579M	S52.579N
S52.591K	S52.591M	S52.591N	S52.592K	S52.592M	S52.592N	S52.599K
S52.599M	S52.599N	S52.601K	S52.601M	S52.601N	S52.602K	S52.602M
S52.602N	S52.609K	S52.609M	S52.609N	S52.611K	S52.611M	S52.611N
S52.612K	S52.612M	S52.612N	S52.613K	S52.613M	S52.613N	S52.614K
S52.614M	S52.614N	S52.615K	S52.615M	S52.615N	S52.616K	S52.616M
S52.616N	S52.621K	S52.622K	S52.629K	S52.691K	S52.691M	S52.691N
S52.692K	S52.692M	S52.692N	S52.699K	S52.699M	S52.699N	S59.001K
S59.002K	S59.009K	S59.011K	S59.012K	S59.019K	S59.021K	S59.022K
S59.029K	S59.031K	S59.032K	S59.039K	S59.041K	S59.042K	S59.049K
S59.091K	S59.092K	S59.099K	S59.101K	S59.102K	S59.109K	S59.111K
S59.112K	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	S59.242K
S59.249K	S59.291K	S59.292K	S59.299K	S62.90XK	S62.91XK	S62.92XK
S62.001A	S62.001K	S62.002A	S62.002K	S62.009A	S62.009K	S62.011A
S62.011K	S62.012A	S62.012K	S62.013A	S62.013K	S62.014A	S62.014K
S62.015A	S62.015K	S62.016A	S62.016K	S62.021A	S62.021K	S62.022A
S62.022K	S62.023A	S62.023K	S62.024A	S62.024K	S62.025A	S62.025K
S62.026A	S62.026K	S62.031A	S62.031K	S62.032A	S62.032K	S62.033A
S62.033K	S62.034A	S62.034K	S62.035A	S62.035K	S62.036A	S62.036K
S62.101K	S62.102K	S62.109K	S62.111K	S62.112K	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	S62.186K	S62.201K	S62.202K	S62.209K	S62.211K	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	S62.511K
S62.512K	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
S62.610K	S62.611K	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	S62.625K	S62.626K	S62.627K	S62.628K	S62.629K	S62.630K
S62.631K	S62.632K	S62.633K	S62.634K	S62.635K	S62.636K	S62.637K
S62.638K	S62.639K	S62.640K	S62.641K	S62.642K	S62.643K	S62.644K
S62.645K	S62.646K	S62.647K	S62.648K	S62.649K	S62.650K	S62.651K
S62.652K	S62.653K	S62.654K	S62.655K	S62.656K	S62.657K	S62.658K
S62.659K	S62.660K	S62.661K	S62.662K	S62.663K	S62.664K	S62.665K
S62.666K	S62.667K	S62.668K	S62.669K	S72.8X1K	S72.8X1M	S72.8X1N
S72.8X2K	S72.8X2M	S72.8X2N	S72.8X9K	S72.8X9M	S72.8X9N	S72.21XK
S72.21XM	S72.21XN	S72.22XK	S72.22XM	S72.22XN	S72.23XK	S72.23XM
S72.23XN	S72.24XK	S72.24XM	S72.24XN	S72.25XK	S72.25XM	S72.25XN
S72.26XK	S72.26XM	S72.26XN	S72.90XK	S72.90XM	S72.90XN	S72.91XK
S72.91XM	S72.91XN	S72.92XK	S72.92XM	S72.92XN	S72.001K	S72.001M
S72.001N	S72.002K	S72.002M	S72.002N	S72.009K	S72.009M	S72.009N
S72.011K	S72.011M	S72.011N	S72.012K	S72.012M	S72.012N	S72.019K
S72.019M	S72.019N	S72.021K	S72.021M	S72.021N	S72.022K	S72.022M
S72.022N	S72.023K	S72.023M	S72.023N	S72.024K	S72.024M	S72.024N
S72.025K	S72.025M	S72.025N	S72.026K	S72.026M	S72.026N	S72.031K
S72.031M	S72.031N	S72.032K	S72.032M	S72.032N	S72.033K	S72.033M
S72.033N	S72.034K	S72.034M	S72.034N	S72.035K	S72.035M	S72.035N
S72.036K	S72.036M	S72.036N	S72.041K	S72.041M	S72.041N	S72.042K
S72.042M	S72.042N	S72.043K	S72.043M	S72.043N	S72.044K	S72.044M
S72.044N	S72.045K	S72.045M	S72.045N	S72.046K	S72.046M	S72.046N
S72.051K	S72.051M	S72.051N	S72.052K	S72.052M	S72.052N	S72.059K
S72.059M	S72.059N	S72.061K	S72.061M	S72.061N	S72.062K	S72.062M
S72.062N	S72.063K	S72.063M	S72.063N	S72.064K	S72.064M	S72.064N
S72.065K	S72.065M	S72.065N	S72.066K	S72.066M	S72.066N	S72.091K
S72.091M	S72.091N	S72.092K	S72.092M	S72.092N	S72.099K	S72.099M
S72.099N	S72.101K	S72.101M	S72.101N	S72.102K	S72.102M	S72.102N
S72.109K	S72.109M	S72.109N	S72.111K	S72.111M	S72.111N	S72.112K
S72.112M	S72.112N	S72.113K	S72.113M	S72.113N	S72.114K	S72.114M
S72.114N	S72.115K	S72.115M	S72.115N	S72.116K	S72.116M	S72.116N
S72.121K	S72.121M	S72.121N	S72.122K	S72.122M	S72.122N	S72.123K
S72.123M	S72.123N	S72.124K	S72.124M	S72.124N	S72.125K	S72.125M
S72.125N	S72.126K	S72.126M	S72.126N	S72.131K	S72.131M	S72.131N
S72.132K	S72.132M	S72.132N	S72.133K	S72.133M	S72.133N	S72.134K
S72.134M	S72.134N	S72.135K	S72.135M	S72.135N	S72.136K	S72.136M
S72.136N	S72.141K	S72.141M	S72.141N	S72.142K	S72.142M	S72.142N
S72.143K	S72.143M	S72.143N	S72.144K	S72.144M	S72.144N	S72.145K
S72.145M	S72.145N	S72.146K	S72.146M	S72.146N	S72.301K	S72.301M
S72.301N	S72.302K	S72.302M	S72.302N	S72.309K	S72.309M	S72.309N
S72.321K	S72.321M	S72.321N	S72.322K	S72.322M	S72.322N	S72.323K
S72.323M	S72.323N	S72.324K	S72.324M	S72.324N	S72.325K	S72.325M
S72.325N	S72.326K	S72.326M	S72.326N	S72.331K	S72.331M	S72.331N
S72.332K	S72.332M	S72.332N	S72.333K	S72.333M	S72.333N	S72.334K
S72.334M	S72.334N	S72.335K	S72.335M	S72.335N	S72.336K	S72.336M
S72.336N	S72.341K	S72.341M	S72.341N	S72.342K	S72.342M	S72.342N
S72.343K	S72.343M	S72.343N	S72.344K	S72.344M	S72.344N	S72.345K
S72.345M	S72.345N	S72.346K	S72.346M	S72.346N	S72.351K	S72.351M
S72.351N	S72.352K	S72.352M	S72.352N	S72.353K	S72.353M	S72.353N
S72.354K	S72.354M	S72.354N	S72.355K	S72.355M	S72.355N	S72.356K
S72.356M	S72.356N	S72.361K	S72.361M	S72.361N	S72.362K	S72.362M
S72.362N	S72.363K	S72.363M	S72.363N	S72.364K	S72.364M	S72.364N
S72.365K	S72.365M	S72.365N	S72.366K	S72.366M	S72.366N	S72.391K
S72.391M	S72.391N	S72.392K	S72.392M	S72.392N	S72.399K	S72.399M
S72.399N	S72.401K	S72.401M	S72.401N	S72.402K	S72.402M	S72.402N
S72.409K	S72.409M	S72.409N	S72.411K	S72.411M	S72.411N	S72.412K
S72.412M	S72.412N	S72.413K	S72.413M	S72.413N	S72.414K	S72.414M
S72.414N	S72.415K	S72.415M	S72.415N	S72.416K	S72.416M	S72.416N
S72.421K	S72.421M	S72.421N	S72.422K	S72.422M	S72.422N	S72.423K
S72.423M	S72.423N	S72.424K	S72.424M	S72.424N	S72.425K	S72.425M
S72.425N	S72.426K	S72.426M	S72.426N	S72.431K	S72.431M	S72.431N
S72.432K	S72.432M	S72.432N	S72.433K	S72.433M	S72.433N	S72.434K
S72.434M	S72.434N	S72.435K	S72.435M	S72.435N	S72.436K	S72.436M
S72.436N	S72.441K	S72.441M	S72.441N	S72.442K	S72.442M	S72.442N
S72.443K	S72.443M	S72.443N	S72.444K	S72.444M	S72.444N	S72.445K
S72.445M	S72.445N	S72.446K	S72.446M	S72.446N	S72.451K	S72.451M
S72.451N	S72.452K	S72.452M	S72.452N	S72.453K	S72.453M	S72.453N
S72.454K	S72.454M	S72.454N	S72.455K	S72.455M	S72.455N	S72.456K
S72.456M	S72.456N	S72.461K	S72.461M	S72.461N	S72.462K	S72.462M
S72.462N	S72.463K	S72.463M	S72.463N	S72.464K	S72.464M	S72.464N
S72.465K	S72.465M	S72.465N	S72.466K	S72.466M	S72.466N	S72.471K
S72.472K	S72.479K	S72.491K	S72.491M	S72.491N	S72.492K	S72.492M
S72.492N	S72.499K	S72.499M	S72.499N	S79.001K	S79.002K	S79.009K
S79.011K	S79.012K	S79.019K	S79.091K	S79.092K	S79.099K	S79.101K
S79.102K	S79.109K	S79.111K	S79.112K	S79.119K	S79.121K	S79.122K
S79.129K	S79.131K	S79.132K	S79.139K	S79.141K	S79.142K	S79.149K
S79.191K	S79.192K	S79.199K	S82.51XK	S82.51XM	S82.51XN	S82.52XK
S82.52XM	S82.52XN	S82.53XK	S82.53XM	S82.53XN	S82.54XK	S82.54XM
S82.54XN	S82.55XK	S82.55XM	S82.55XN	S82.56XK	S82.56XM	S82.56XN
S82.61XK	S82.61XM	S82.61XN	S82.62XK	S82.62XM	S82.62XN	S82.63XK
S82.63XM	S82.63XN	S82.64XK	S82.64XM	S82.64XN	S82.65XK	S82.65XM
S82.65XN	S82.66XK	S82.66XM	S82.66XN	S82.90XK	S82.90XM	S82.90XN
S82.91XK	S82.91XM	S82.91XN	S82.92XK	S82.92XM	S82.92XN	S82.001K
S82.001M	S82.001N	S82.002K	S82.002M	S82.002N	S82.009K	S82.009M
S82.009N	S82.011K	S82.011M	S82.011N	S82.012K	S82.012M	S82.012N
S82.013K	S82.013M	S82.013N	S82.014K	S82.014M	S82.014N	S82.015K
S82.015M	S82.015N	S82.016K	S82.016M	S82.016N	S82.021K	S82.021M
S82.021N	S82.022K	S82.022M	S82.022N	S82.023K	S82.023M	S82.023N
S82.024K	S82.024M	S82.024N	S82.025K	S82.025M	S82.025N	S82.026K
S82.026M	S82.026N	S82.031K	S82.031M	S82.031N	S82.032K	S82.032M
S82.032N	S82.033K	S82.033M	S82.033N	S82.034K	S82.034M	S82.034N
S82.035K	S82.035M	S82.035N	S82.036K	S82.036M	S82.036N	S82.041K
S82.041M	S82.041N	S82.042K	S82.042M	S82.042N	S82.043K	S82.043M
S82.043N	S82.044K	S82.044M	S82.044N	S82.045K	S82.045M	S82.045N
S82.046K	S82.046M	S82.046N	S82.091K	S82.091M	S82.091N	S82.092K
S82.092M	S82.092N	S82.099K	S82.099M	S82.099N	S82.101K	S82.101M
S82.101N	S82.102K	S82.102M	S82.102N	S82.109K	S82.109M	S82.109N
S82.111K	S82.111M	S82.111N	S82.112K	S82.112M	S82.112N	S82.113K
S82.113M	S82.113N	S82.114K	S82.114M	S82.114N	S82.115K	S82.115M
S82.115N	S82.116K	S82.116M	S82.116N	S82.121K	S82.121M	S82.121N
S82.122K	S82.122M	S82.122N	S82.123K	S82.123M	S82.123N	S82.124K
S82.124M	S82.124N	S82.125K	S82.125M	S82.125N	S82.126K	S82.126M
S82.126N	S82.131K	S82.131M	S82.131N	S82.132K	S82.132M	S82.132N
S82.133K	S82.133M	S82.133N	S82.134K	S82.134M	S82.134N	S82.135K
S82.135M	S82.135N	S82.136K	S82.136M	S82.136N	S82.141K	S82.141M
S82.141N	S82.142K	S82.142M	S82.142N	S82.143K	S82.143M	S82.143N
S82.144K	S82.144M	S82.144N	S82.145K	S82.145M	S82.145N	S82.146K
S82.146M	S82.146N	S82.151K	S82.151M	S82.151N	S82.152K	S82.152M
S82.152N	S82.153K	S82.153M	S82.153N	S82.154K	S82.154M	S82.154N
S82.155K	S82.155M	S82.155N	S82.156K	S82.156M	S82.156N	S82.161K
S82.162K	S82.169K	S82.191K	S82.191M	S82.191N	S82.192K	S82.192M
S82.192N	S82.199K	S82.199M	S82.199N	S82.201K	S82.201M	S82.201N
S82.202K	S82.202M	S82.202N	S82.209K	S82.209M	S82.209N	S82.221K
S82.221M	S82.221N	S82.222K	S82.222M	S82.222N	S82.223K	S82.223M
S82.223N	S82.224K	S82.224M	S82.224N	S82.225K	S82.225M	S82.225N
S82.226K	S82.226M	S82.226N	S82.231K	S82.231M	S82.231N	S82.232K
S82.232M	S82.232N	S82.233K	S82.233M	S82.233N	S82.234K	S82.234M
S82.234N	S82.235K	S82.235M	S82.235N	S82.236K	S82.236M	S82.236N
S82.241K	S82.241M	S82.241N	S82.242K	S82.242M	S82.242N	S82.243K
S82.243M	S82.243N	S82.244K	S82.244M	S82.244N	S82.245K	S82.245M
S82.245N	S82.246K	S82.246M	S82.246N	S82.251K	S82.251M	S82.251N
S82.252K	S82.252M	S82.252N	S82.253K	S82.253M	S82.253N	S82.254K
S82.254M	S82.254N	S82.255K	S82.255M	S82.255N	S82.256K	S82.256M
S82.256N	S82.261K	S82.261M	S82.261N	S82.262K	S82.262M	S82.262N
S82.263K	S82.263M	S82.263N	S82.264K	S82.264M	S82.264N	S82.265K
S82.265M	S82.265N	S82.266K	S82.266M	S82.266N	S82.291K	S82.291M
S82.291N	S82.292K	S82.292M	S82.292N	S82.299K	S82.299M	S82.299N
S82.301K	S82.301M	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	S82.402M	S82.402N	S82.409K
S82.409M	S82.409N	S82.421K	S82.421M	S82.421N	S82.422K	S82.422M
S82.422N	S82.423K	S82.423M	S82.423N	S82.424K	S82.424M	S82.424N
S82.425K	S82.425M	S82.425N	S82.426K	S82.426M	S82.426N	S82.431K
S82.431M	S82.431N	S82.432K	S82.432M	S82.432N	S82.433K	S82.433M
S82.433N	S82.434K	S82.434M	S82.434N	S82.435K	S82.435M	S82.435N
S82.436K	S82.436M	S82.436N	S82.441K	S82.441M	S82.441N	S82.442K
S82.442M	S82.442N	S82.443K	S82.443M	S82.443N	S82.444K	S82.444M
S82.444N	S82.445K	S82.445M	S82.445N	S82.446K	S82.446M	S82.446N
S82.451K	S82.451M	S82.451N	S82.452K	S82.452M	S82.452N	S82.453K
S82.453M	S82.453N	S82.454K	S82.454M	S82.454N	S82.455K	S82.455M
S82.455N	S82.456K	S82.456M	S82.456N	S82.461K	S82.461M	S82.461N
S82.462K	S82.462M	S82.462N	S82.463K	S82.463M	S82.463N	S82.464K
S82.464M	S82.464N	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
S82.832N	S82.839K	S82.839M	S82.839N	S82.841K	S82.841M	S82.841N
S82.842K	S82.842M	S82.842N	S82.843K	S82.843M	S82.843N	S82.844K
S82.844M	S82.844N	S82.845K	S82.845M	S82.845N	S82.846K	S82.846M
S82.846N	S82.851K	S82.851M	S82.851N	S82.852K	S82.852M	S82.852N
S82.853K	S82.853M	S82.853N	S82.854K	S82.854M	S82.854N	S82.855K
S82.855M	S82.855N	S82.856K	S82.856M	S82.856N	S82.861K	S82.861M
S82.861N	S82.862K	S82.862M	S82.862N	S82.863K	S82.863M	S82.863N
S82.864K	S82.864M	S82.864N	S82.865K	S82.865M	S82.865N	S82.866K
S82.866M	S82.866N	S82.871K	S82.871M	S82.871N	S82.872K	S82.872M
S82.872N	S82.873K	S82.873M	S82.873N	S82.874K	S82.874M	S82.874N
S82.875K	S82.875M	S82.875N	S82.876K	S82.876M	S82.876N	S82.891K
S82.891M	S82.891N	S82.892K	S82.892M	S82.892N	S82.899K	S82.899M
S82.899N	S89.001K	S89.002K	S89.009K	S89.011K	S89.012K	S89.019K
S89.021K	S89.022K	S89.029K	S89.031K	S89.032K	S89.039K	S89.041K
S89.042K	S89.049K	S89.091K	S89.092K	S89.099K	S89.101K	S89.102K
S89.109K	S89.111K	S89.112K	S89.119K	S89.121K	S89.122K	S89.129K
S89.131K	S89.132K	S89.139K	S89.141K	S89.142K	S89.149K	S89.191K
S89.192K	S89.199K	S89.201K	S89.202K	S89.209K	S89.211K	S89.212K
S89.219K	S89.221K	S89.222K	S89.229K	S89.291K	S89.292K	S89.299K
S89.301K	S89.302K	S89.309K	S89.311K	S89.312K	S89.319K	S89.321K
S89.322K	S89.329K	S89.391K	S89.392K	S89.399K	S92.001K	S92.002K
S92.009K	S92.011K	S92.012K	S92.013K	S92.014K	S92.015K	S92.016K
S92.021K	S92.022K	S92.023K	S92.024K	S92.025K	S92.026K	S92.031K
S92.032K	S92.033K	S92.034K	S92.035K	S92.036K	S92.041K	S92.042K
S92.043K	S92.044K	S92.045K	S92.046K	S92.051K	S92.052K	S92.053K
S92.054K	S92.055K	S92.056K	S92.061K	S92.062K	S92.063K	S92.064K
S92.065K	S92.066K	S92.101K	S92.102K	S92.109K	S92.111K	S92.112K
S92.113K	S92.114K	S92.115K	S92.116K	S92.121K	S92.122K	S92.123K
S92.124K	S92.125K	S92.126K	S92.131K	S92.132K	S92.133K	S92.134K
S92.135K	S92.136K	S92.141K	S92.142K	S92.143K	S92.144K	S92.145K
S92.146K	S92.151K	S92.152K	S92.153K	S92.154K	S92.155K	S92.156K
S92.191K	S92.192K	S92.199K	S92.201K	S92.202K	S92.209K	S92.211K
S92.212K	S92.213K	S92.214K	S92.215K	S92.216K	S92.221K	S92.222K
S92.223K	S92.224K	S92.225K	S92.226K	S92.231K	S92.232K	S92.233K
S92.234K	S92.235K	S92.236K	S92.241K	S92.242K	S92.243K	S92.244K
S92.245K	S92.246K	S92.251K	S92.252K	S92.253K	S92.254K	S92.255K
S92.256K	S92.301A	S92.301K	S92.302A	S92.302K	S92.309A	S92.309K
S92.311K	S92.312K	S92.313A	S92.313K	S92.314A	S92.314K	S92.315A
S92.315K	S92.316A	S92.316K	S92.321A	S92.321K	S92.322A	S92.322K
S92.323A	S92.323K	S92.324A	S92.324K	S92.325A	S92.325K	S92.326A
S92.326K	S92.331A	S92.331K	S92.332A	S92.332K	S92.333A	S92.333K
S92.334A	S92.334K	S92.335A	S92.335K	S92.336A	S92.336K	S92.341A
S92.341K	S92.342A	S92.342K	S92.343A	S92.343K	S92.344A	S92.344K
S92.345A	S92.345K	S92.346A	S92.346K	S92.351A	S92.351K	S92.352A
S92.352K	S92.353A	S92.353K	S92.354A	S92.354K	S92.355A	S92.355K
S92.356A	S92.356K	S92.401K	S92.402K	S92.403K	S92.404K	S92.405K
S92.406K	S92.411K	S92.412K	S92.413K	S92.414K	S92.415K	S92.416K
S92.421K	S92.422K	S92.423K	S92.424K	S92.425K	S92.426K	S92.491K
S92.492K	S92.499K	S92.501K	S92.502K	S92.503K	S92.504K	S92.505K
S92.506K	S92.511K	S92.512K	S92.513K	S92.514K	S92.515K	S92.516K
S92.521K	S92.522K	S92.523K	S92.524K	S92.525K	S92.526K	S92.531K
S92.532K	S92.533K	S92.534K	S92.535K	S92.536K	S92.591K	S92.592K
S92.599K	S92.901K	S92.902K	S92.909K	S92.911K	S92.912K	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

Link to References

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.