HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Z-65-013
Topic:
Telestroke
Section:
Miscellaneous
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
October 2018
Annual Review:
July 2018
 
 

Telestroke is an application of telemedicine bringing stroke specialists to hospitals lacking stroke expertise. Telestroke network models include both distributed and hub-and-spoke models providing evaluation and treatment of acute stroke including administration of intravenous tissue plasminogen activator (tPA) and/or selection of individuals who are candidates for endovascular therapy. Telestroke serves in multiple capacities to support stroke systems of care which facilitate communication among providers throughout a stroke system composed of comprehensive stroke centers, primary stroke centers, acute stroke ready hospitals, non-accredited hospitals, pre-hospital care by emergency medical services and post-acute care. Telestroke bridges geographical and temporal barriers that can introduce disparities to access to stroke services.

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

Stroke Telemedicine (Telestroke)

Provider interactive telemedicine services may be considered medically necessary when telestroke services are reported.

The following telestroke services apply when reported by a neurologist:

  • Emergency department visit; or
  • In-patient initial telestroke consultations; or
  • In-patient follow-up telestroke consultations; or
  • Pre-hospital telestroke evaluation of individuals with acute stroke being evaluated by emergency medical services (EMS); or
  • Post-acute evaluation of stroke individuals residing in either inpatient rehabilitation facilities or skilled nursing facilities during the 90 day period after index hospitalization for stroke; or
  • Telehealth originating site facility fee.

The neurologist delivering acute stroke intervention via telestroke services must be credentialed by the Plan and licensed in the state where the hub facility is physically located and where telestroke services are rendered to the individual. 

The neurologist or radiologist performing the imaging interpretation services via teleradiology must be credentialed by the Plan and licensed in the state where the spoke facility is physically located and where telestroke services are rendered to the individual. 

Computed tomography (CT) images must be transmitted in a real-time or near real-time mode (less than two (2) minutes) to ensure that the telestroke neurologist or radiologist can collaborate with the spoke facility ordering physician and radiology technicians performing the studies.

At a minimum, hub and spoke facilities must be:

  • Connected via broadband or the necessary bandwidth to ensure real-time or near real-time image acquisition through transmission for final image display; and   
  • Hub and spoke facilities must have a picture archiving and communications system (PACS); and
  • Hub facilities must have minimum monitor resolution (matrix) of 512 x 512 at 8-bit pixel depth.

G0406

G0407

G0408

G0425

G0426

G0427

G0508

G0509

Q3014

 

 

 

 

 


Covered Diagnosis Codes for Procedure Codes G0406, G0407, G0408, G0425, G0426, G0427, G0508, G0509, Q3014

I63.00

I63.011

I63.012

I63.013

I63.02

I63.031

I63.032

I63.033

I63.09

I63.10

I63.111

I63.112

I63.113

I63.12

I63.131

I63.132

I63.133

I63.19

I63.20

I63.211

I63.212

I63.213

I63.22

I63.231

I63.232

I63.233

I63.29

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.331

I63.332

I63.333

I63.341

I63.342

I63.343

I63.39

I63.40

I63.411

I63.412

I63.413

I63.421

I63.422

I63.423

I63.431

I63.432

I63.433

I63.441

I63.442

I63.443

I63.49

I63.50

I63.511

I63.512

I63.513

I63.521

I63.522

I63.523

I63.531

I63.532

I63.533

I63.541

I63.542

I63.543

I63.59

I63.6

I63.81

I63.89

I63.9

Z92.82

 

 

 


Place of Service: Inpatient/Outpatient

Telestroke 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.



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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.

    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.