HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Z-24-104
Topic:
Miscellaneous Services
Section:
Miscellaneous
Effective Date:
March 6, 2020
Issued Date:
March 23, 2020
Last Revision Date:
March 2020
Annual Review:
May 2019
 
 

This policy addresses those services considered to be miscellaneous and are typically not covered services.

Policy Position

ALL services on this policy are non-covered for ONE of the following reasons:

·  The service is considered experimental/investigational; or

·  The service is considered not medically necessary because it does not  meet the definition of medically necessary; or

·  The service is a program exclusion/not a benefit; or

·   No professional service has been rendered.

Experimental/Investigational

The following services are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature:

  • Adoptive Immunotherapy
  • Anal fistula plug
  • Bioimpedance spectroscopy for lymphedema
  • Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)
  • Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) (ImmuKnow®)
  • Electromagnetic Navigational Bronchoscopy (ENB) (e.g., SuperDimension Bronchus System, inReachTM System, iLogicTM Electromagnetic Navigation BronchoscopyTM, ig4TM EndoBronchial System )
  • Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
  • Endoscopic CryoSpray ablation of the esophagus
  • Ferriscan
  • Multivariate analysis of patient-specific findings with quantifiable computer probability assessment, including report
  • Neuro-selective current perception threshold (CPT)/Sensory Nerve Conduction Test
  • Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or arterial, venous, or capillary glucose; and/or potassium concentration
  • Per-oral Endoscopic Myotomy (POEM) for treatment of esophageal achalasia
  • pH; exhaled breath condensate
  • Posturography (dynamic or static)
  • PreDx (Diabetes Risk Score)
  • Saliva test, hormone level; to assess preterm labor
  • Saliva test, hormone level; during menopause
  • Tenotomy of elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow; percutaneous)
  • Thromboxane metabolite(s), including thromboxane if performed, urine
  • Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
  • InfraScanner Handheld Brain Hematoma Screening System For Early Detection of Intracranial Hemorrhage (ICH)

24357  

29999  

31627  

43499  

46707  

53860  

76498

81506  

83987  

84431  

84999  

86352  

92548  

92549

93702

99199  

G0255  

G9147

S2107  

S2300  

S3650  

S3652  

 

 

 

 

 

 


Not Medically Necessary

The following services are considered not medically necessary:

  • Defecography
  • Grenz Ray Therapy
  • Hair analysis
  • Lixiscope Service

P2031

74270

77499

 

 

 

 


Program Exclusion/Not a Benefit

A program exclusion/not a benefit is defined as EITHER ONE of the following:

  • Services generally not covered under the specified program(s);or
  • Groups define benefits, and determine coverage

The following services are considered a program exclusion/not a benefit, and therefore non-covered:

  • Casted impressions for special shoes
  • EROS-Clitoral Therapy Device as a treatment of female sexual dysfunction
  • Hearing aid evaluation
  • Recreational or educational therapy (inpatient)

92590

92591

92592

92593

92594

92595

A9270

S0395

 

 

 

 

 

 


No Professional Service Rendered

When no professional service is rendered the service does not require direct patient care or contact.

The following services are considered no professional service rendered, and therefore non-covered:

  • Broken appointments
  • Glucola (glucose preparation)
  • Mileage for medical visit
  • Team conferences
  • Treatment planning and care coordination management for cancer initial treatment
  • Treatment planning and care coordination management for cancer established patient with a change of regimen

99366

99367

99368

A9270

S0353

S0354

 


C9751

 

 

 

 

 

 


Related Policies

Refer to Medical Policy Z-67, Experimental/Investigational Services, for additional information.

Refer to Medical Policy Z-11, Definition of Medical Necessity, for additional information.

Refer to Medical Policy G-27, Clinical Trials, for additional information.


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

A miscellaneous service 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



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, and subject to the applicable laws of your state.


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.