Experimental/Investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.
This policy addresses services considered to be experimental/investigational and, therefore, non-covered services.
Services meeting ANY of the following criteria are considered experimental/investigational:
Procedure codes identified within this policy are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature.
Nervous System
Procedure Code |
Description |
0766T |
Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve |
0767T |
Transcutaneous magnetic stimulation by focused low-frequency electromagnetic pulse, peripheral nerve, initial treatment, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve (List separately in addition to code for primary |
0776T
|
Therapeutic induction of intra-brain hypothermia, including placement of a mechanical temperature-controlled cooling device to the neck over carotids and head, including monitoring (eg, vital signs and sport concussion assessment tool 5 [SCAT5]), 30 minutes of treatment |
A4593 |
Neuromodulation stimulator system, adjunct to rehabilitation therapy regime |
A4594 |
Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece each |
Eye
Procedure Code |
Description |
0100T |
Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy |
0198T |
Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report
|
0308T |
Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis |
0329T |
Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report |
0333T |
Visual evoked potential, screening of visual acuity, automated, with report |
0378T |
Visual field assessment, with concurrent real time data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional |
0379T |
Visual field assessment, with concurrent real time data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional |
0444T |
Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral |
0445T |
Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral |
0469T |
Retinal polarization scan, ocular screening with on-site automated results, bilateral |
0472T |
Device evaluation, interrogation, and initial programming of intraocular retinal electrode array (i.e., retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional |
0473T |
Device evaluation and interrogation of intraocular retinal electrode array (i.e., retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional |
0506T |
Macular pigment optical density measurement by heterochromatic flicker photometry, unilateral or bilateral, with interpretation and report |
0604T |
Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; initial device provision, set-up and patient education on use of equipment |
0605T |
Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days |
0606T |
Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days |
0615T |
Eye-movement analysis without spatial calibration, with interpretation and report |
0616T |
Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens |
0617T |
Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens |
0618T |
Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange |
0621T |
Trabeculostomy ab interno by laser |
0622T |
Trabeculostomy ab interno by laser; with use of ophthalmic endoscope |
0660T |
Implantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach |
0661T |
Removal and reimplantation of anterior segment intraocular nonbiodegradable drug-eluting implant |
0687T |
Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session |
0688T |
Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month |
0704T |
Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment |
0705T |
Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days |
0706T |
Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month |
0730T |
Trabeculotomy by laser, including optical coherence tomography (OCT) guidance |
0810T |
Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies |
92145 |
Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report |
95919 |
Quantitative pupillometry with physician or other qualified health care professional interpretation and report, unilateral or bilateral |
C1839 |
Iris prosthesis |
L8608 |
Miscellaneous external component, supply or accessory for use with the Argus II retinal prosthesis system |
Face, Head and Neck
Procedure Code |
Description |
0639T |
Wireless skin sensor thermal anisotropy measurement(s) and assessment of flow in cerebrospinal fluid shunt, including ultrasound guidance, when performed |
0662T |
Scalp cooling, mechanical; initial measurement and calibration of cap |
0663T |
Scalp cooling, mechanical; placement of device, monitoring, and removal of device (list separately in addition to code for primary procedure) |
0673T |
Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance |
Ear, Nose and Throat
Procedure Code |
Description |
0485T |
Optical coherence tomography (OCT) of middle ear, with interpretation and report; unilateral |
0486T |
Optical coherence tomography (OCT) of middle ear, with interpretation and report; bilateral |
0583T |
Tympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia |
0725T |
Vestibular device implantation, unilateral |
0726T |
Removal of implanted vestibular device, unilateral |
0727T |
Removal and replacement of implanted vestibular device, unilateral |
0728T |
Diagnostic analysis of vestibular implant, unilateral; with initial programming |
0729T |
Diagnostic analysis of vestibular implant, unilateral; with subsequent programming |
0783T |
Transcutaneous auricular neurostimulation, set-up, calibration, and patient education on use of equipment |
31242 |
Surgical nasal/sinus endoscopy; radiofrequency ablation, posterior nasal nerve |
31243 |
Surgical nasal/sinus endoscopy; cryoablation, posterior nasal nerve |
30468 |
Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) |
30469 |
Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling |
Respiratory System
Procedure Code |
Description |
0174T |
Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation |
0175T |
Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation |
0607T |
Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ecg data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment |
0608T |
Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ecg data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional |
0632T |
Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance |
0781T |
Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; bilateral mainstem bronchi |
0782T |
Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; unilateral mainstem bronchus |
C1601 |
Endoscope, single-use (i.e. disposable), pulmonary, imaging/illumination device (insertable) |
K1037 |
Docking station for use with oral device/appliance used to reduce upper airway collapsibility |
Gastrointestinal System
Procedure Code |
Description |
0652T |
Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
0653T |
Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple |
0654T |
Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter |
0736T |
Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter |
0748T
|
Injections of stem cell product into perianal peri-fistular soft tissue, including fistula preparation (e.g., removal of setons, fistula curettage, closure of internal openings) |
0771T
|
Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older |
0772T
|
Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; each additional 15 minutes intraservice time (List separately in |
0773T
|
Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older |
0774T
|
Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes intraservice time (List separately in |
0779T
|
Gastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report |
91022 |
Duodenal motility (manometric) study |
A4563 |
Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each |
A9268 |
Programmer for transient, orally ingested capsule |
A9269
|
Programable, transient, orally ingested capsule, for use with external programmer, per month |
C1748 |
Endoscope, single-use (i.e. disposable), upper GI, imaging/illumination device (insertable) |
C9779 |
Endoscopic submucosal dissection (ESD), including endoscopy or colonoscopy, mucosal closure, when performed |
Skin and Subcutaneous Tissue
Procedure Code |
Description |
0479T |
Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children |
0480T |
Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (list separately in addition to code for primary procedure) |
0552T |
Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional |
0598T |
Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (eg, lower extremity) |
0599T |
Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; each additional anatomic site (eg, upper extremity) (list separately in addition to code for primary procedure) |
0640T |
Noncontact near-infrared spectroscopy studies of flap or wound (i.e., for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition, interpretation and report, each flap or wound |
0658T |
Electrical impedance spectroscopy of one (1) or more skin lesions for automated melanoma risk score |
0700T |
Molecular fluorescent imaging of suspicious nevus; first lesion |
0701T |
Molecular fluorescent imaging of suspicious nevus; each additional lesion (list separately in addition to code for primary procedure) |
96931 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion |
96932 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion |
96933 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion |
96934 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (list separately in addition to code for primary procedure) |
96935 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (list separately in addition to code for primary procedure) |
96936 |
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (list separately in addition to code for primary procedure) |
C1832 |
Autograft suspension, including cell processing and application, and all system components |
C9250 |
Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 ml |
Cardiovascular System
Procedure Code |
Description |
0266T |
Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming and repositioning, when performed) |
0267T |
Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) |
0268T |
Implantation or replacement of carotid baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) |
0269T |
Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning when performed) |
0270T |
Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) |
0271T |
Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) |
0272T |
Interrogation device evaluation (in person), carotid sinus barorelfex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (i.e., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); |
0273T |
Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (i.e., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming |
0484T |
Transcatheter mitral valve implantation/replacement (tmvi) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) |
0505T |
Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion |
0518T |
Removal of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing |
0521T |
Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimulator for left ventricular pacing |
0522T |
Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, wireless cardiac stimulator for left ventricular pacing |
0523T |
Intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention (list separately in addition to code for primary procedure) |
0525T |
Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor) |
0526T |
Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only |
0527T |
Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only |
0528T |
Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report |
0529T |
Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report |
0530T |
Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor) |
0531T |
Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only |
0532T |
Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only |
0541T |
Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study |
0542T |
Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study; interpretation and report |
0543T |
Transapical mitral valve repair, including transthoracic echocardiography, when performed, with placement of artificial chordae tendineae |
0544T |
Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture |
0545T |
Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach |
0553T |
Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention |
0569T |
Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis |
0570T |
Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (list separately in addition to code for primary procedure) |
0571T |
Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed |
0572T |
Insertion of substernal implantable defibrillator electrode |
0573T |
Removal of substernal implantable defibrillator electrode |
0574T |
Repositioning of previously implanted substernal implantable defibrillator-pacing electrode |
0575T |
Programming device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional |
0576T |
Interrogation device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter |
0577T |
Electrophysiologic evaluation of implantable cardioverter-defibrillator system with substernal electrode (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) |
0578T |
Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional |
0579T |
Interrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results |
0580T |
Removal of substernal implantable defibrillator pulse generator only |
0613T |
Percutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance by the proceduralist, when performed |
0620T |
Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed |
0644T |
Transcatheter removal or debulking of intracardiac mass (i.e., vegetations, thrombus) via suction (i.e., vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated blood, including imaging guidance, when performed |
0645T |
Transcatheter implantation of coronary sinus reduction device including vascular access and closure, right heart catheterization, venous angiography, coronary sinus angiography, imaging guidance, and supervision and interpretation, when performed |
0646T |
Transcatheter tricuspid valve implantation/replacement (ttvi) with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed |
0659T |
Transcatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (i.e., fluoroscopy), angiography, and radiologic supervision and interpretation |
0674T |
Laparoscopic insertion of new or replacement of permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including an implantable pulse generator and diaphragmatic lead(s) |
0675T |
Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first lead |
0676T |
Laparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional lead (list separately in addition to code for primary procedure) |
0677T |
Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first repositioned lead |
0678T |
Laparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional repositioned lead (list separately in addition to code for primary procedure) |
0679T |
Laparoscopic removal of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function |
0680T |
Insertion or replacement of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing lead(s) |
0681T |
Relocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing dual leads |
0682T |
Removal of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function |
0683T |
Programming device evaluation (in-person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function |
0684T |
Peri-procedural device evaluation (in-person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review, and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function |
0685T |
Interrogation device evaluation (in-person) with analysis, review and report by a physician or other qualified health care professional, including connection, recording and disconnection per patient encounter, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function |
0695T |
Body surface-activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of implant or replacement |
0696T |
Body surface-activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of follow-up interrogation or programming device evaluation |
0744T |
Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft (e.g., polyester, ePTFE, bovine pericardium), when performed |
0745T |
Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance |
0746T |
Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan |
0747T |
Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia |
0764T |
Assistive algorithmic electrocardiogram risk-based assessment for cardiac dysfunction (e.g., low-ejection fraction, pulmonary hypertension, hypertrophic cardiomyopathy); related to concurrently performed electrocardiogram (List separately in addition to code for primary procedure) |
0765T
|
Assistive algorithmic electrocardiogram risk-based assessment for cardiac dysfunction (e.g., low-ejection fraction, pulmonary hypertension, hypertrophic cardiomyopathy); related to previously performed electrocardiogram |
0793T
|
Percutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance |
0805T
|
Transcatheter superior and inferior vena cava prosthetic valve implantation (i.e., caval valve implantation [CAVI]); percutaneous femoral vein approach |
0806T |
Transcatheter superior and inferior vena cava prosthetic valve implantation (i.e., caval valve implantation [CAVI]); open femoral vein approach |
33267 |
Exclusion of left atrial appendage, open, any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip) |
33268 |
Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip) (list separately in addition to code for primary procedure) |
33269 |
Exclusion of left atrial appendage, thoracoscopic, any method (i.e., excision, isolation via stapling, oversewing, ligation, plication, clip) |
33440 |
Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure) |
92972 |
Coronary transluminal lithotripsy |
93895 |
Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral |
C1825 |
Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s) |
C9758 |
Blinded procedure for NYHA class III/IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study |
C9759 |
Transcatheter intraoperative blood vessel microinfusion(s) (i.e., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when performed |
C9760 |
Non-randomized, non-blinded procedure for nyha class II, III, IV heart failure; transcatheter implantation of interatrial shunt, including right and left heart catheterization, transeptal puncture, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (i.e., ultrasound, fluoroscopy), performed in an approved investigational device exemption (IDE) study |
C9764 |
Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed |
C9765 |
Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed |
C9766 |
Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed |
C9767 |
Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed |
C9772 |
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed |
C9773 |
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed |
C9774 |
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed |
C9775 |
Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed |
C9780 |
Insertion of central venous catheter through central venous occlusion via inferior and superior approaches (i.e., inside-out technique), including imaging guidance |
C9782 |
Blinded procedure for New York Heart Association (NYHA) class ii or iii heart failure, or Canadian cardiovascular society (ccs) class iii or iv chronic refractory angina; transcatheter intramyocardial transplantation of autologous bone marrow cells (e.g., mononuclear) or placebo control, autologous bone marrow harvesting and preparation for transplantation, left heart catheterization including ventriculography, all laboratory services, and all imaging with or without guidance (e.g., transthoracic echocardiography, ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study |
C9783 |
Blinded procedure for transcatheter implantation of coronary sinus reduction device or placebo control, including vascular access and closure, right heart catheterization, venous and coronary sinus angiography, imaging guidance and supervision and interpretation when performed in an approved investigational device exemption (ide) study |
C9793 |
3D predictive model generation for pre-planning of a cardiac procedure, using data from cardiac computed tomographic angiography with report |
K1030 |
External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only |
Q0035 |
Cardiokymyography (CKG) |
S3902 |
Ballistocardiogram |
S9025 |
Omnicardiogram/cardiointegram |
Musculoskeletal System
Procedure Code |
Description |
0200T |
Percutaneous sacral augmentation (Sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one (1) or more needles, includes imaging guidance and bone biopsy, when performed |
0201T |
Percutaneous sacral augmentation (Sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two (2) or more needles, includes imaging guidance and bone biopsy, when performed |
0202T |
Posterior vertebral joint(s) arthroplasty (i.e., facet joint(s) replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine |
0219T |
Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical |
0220T |
Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic |
0221T |
Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar |
0222T |
Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (list separately in addition to code for primary procedure) |
0263T |
Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest |
0264T |
Intramuscular autologous bone marrow cell therapy with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest |
0265T |
Intramuscular aulogous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy |
0489T |
Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells |
0490T |
Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands |
0547T |
Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score |
0565T |
Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation |
0566T |
Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral |
0594T |
Osteotomy, humerus, with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments, computations of adjustment schedules, and management of the intramedullary lengthening device |
0691T |
Automated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report |
0717T |
Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs |
0718T |
Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral |
0719T |
Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment |
0778T |
Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function |
0784T |
Insertion or replacement of percutaneous electrode array, spinal, with integrated neurostimulator, including imaging guidance, when performed |
0785T |
Revision or removal of neurostimulator electrode array, spinal, with integrated neurostimulator |
0815T |
Ultrasound-based radiofrequency echographic multi-spectrometry (REMS), bone density study and fracture-risk assessment, 1 or more sites, hips, pelvis or spine |
77089 |
Trabecular bone score (tbs), structural condition of the bone microarchitecture; using dual x-ray absorptiometry (dxa) or other imaging data on gray-scale variogram, calculation, with interpretation and report on fracture-risk |
77090 |
Trabecular bone score (tbs), structural condition of the bone microarchitecture; technical preparation and transmission of data for analysis to be performed elsewhere |
77091 |
Trabecular bone score (tbs), structural condition of the bone microarchitecture; technical calculation only |
77092 |
Trabecular bone score (tbs), structural condition of the bone microarchitecture; interpretation and report on fracture-risk only by other qualified health care professional |
97037 |
Low-level laser therapy for post-operative pain reduction |
C1734 |
Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) |
S2348 |
Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple |
L2006 |
Knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated |
L8701 |
Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
L8702 |
Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated |
Genitourinary System
Procedure Code |
Description |
0567T |
Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound |
0568T |
Introduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound |
0596T |
Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement |
0597T |
Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement; replacement |
0672T |
Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence |
0811T |
Remote multi-day complex uroflowmetry (eg, calibrated electronic equipment); set up and patient education on use of equipment |
0812T |
Remote multi-day complex uroflowmetry (eg, calibrated electronic equipment); device supply with automated report generation, up to 10 days |
52284 |
Cystourethroscopy, with urethral mechanical dilation and drug delivery by drug-coated balloon catheter |
53451 |
Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance |
53452 |
Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance |
53453 |
Periurethral transperineal adjustable balloon continence device; removal, each balloon |
53454 |
Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume |
57465 |
Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (list separately in addition to code for primary procedure) |
E2001 |
Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system and/or fecal management |
Endocrine System
Procedure Code |
Description |
0338T |
Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral |
0339T |
Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral |
0602T |
Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent |
0603T |
Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours |
0686T |
Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance |
C9790 |
Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including image guidance |
Injection
Procedure Code |
Description |
0708T |
Intradermal cancer immunotherapy; preparation and initial injection |
0709T |
Intradermal cancer immunotherapy; each additional injection (list separately in addition to code for primary procedure) |
0732T |
Immunotherapy administration with electroporation, intramuscular |
Miscellaneous
Procedure Code |
Description |
0342T |
Therapeutic apheresis with selective HDL delipidation and plasma reinfusion |
0358T |
Bioelectrical impedance analysis whole body composition assessment, with interpretation and report |
0422T |
Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral |
0437T |
Implantation of non-biologic or synthetic implant (i.e., polypropylene) for fascial reinforcement of the abdominal wall (list separately in addition to primary procedure) |
0488T |
Preventive behavior change, online/electronic structured intensive program for prevention of diabetes using a standardized diabetes prevention program curriculum, provided to an individual, per 30 days |
0546T |
Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report |
0559T |
Anatomic model 3D-printed from image data set(s); first individually prepared and processed component of an anatomic structure |
0560T |
Anatomic model 3D-printed from image data set(s); each additional individually prepared and processed component of an anatomic structure (list separately in addition to code for primary procedure) |
0561T |
Anatomic guide 3D-printed and designed from image data set(s); first anatomic guide |
0562T |
Anatomic guide 3D-printed and designed from image data set(s); each additional anatomic guide (list separately in addition to code for primary procedure) |
0600T |
Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous |
0601T |
Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous |
0689T |
Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (i.e., organ, gland, tissue, target structure) |
0690T |
Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report, obtained with diagnostic ultrasound examination of the same anatomy (i.e., organ, gland, tissue, target structure) (list separately in addition to code for primary procedure) |
0692T |
Therapeutic ultrafiltration |
0693T |
Comprehensive full body computer-based markerless 3D kinematic and kinetic motion analysis and report |
0694T |
3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3-dimensional automatic specimen reorientation, interpretation and report, real-time intraoperative |
0721T |
Quantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained without concurrent CT examination of any structure contained in previously acquired diagnostic imaging |
0723T |
Quantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained without diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session |
0731T |
Augmentative AI-based facial phenotype analysis with report |
0737T |
Xenograft implantation into the articular surface |
0791T |
Motor-cognitive, semi-immersive virtual reality–facilitated gait training, each 15 minutes (List separately in addition to code for primary procedure) |
0794T |
Patient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results which have been previously interpreted and reported separately |
0820T |
Continuous in-person monitoring and intervention (eg, psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; first physician or other qualified health care professional, each hour |
0821T |
Continuous in-person monitoring and intervention (eg, psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; second physician or other qualified health care professional, concurrent with first physician or other qualified health care professional, each hour |
0822T |
Continuous in-person monitoring and intervention (eg, psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; clinical staff under the direction of a physician or other qualified health care professional, concurrent with first physician or other qualified health care professional, each hour (List separately in addition to code for primary procedure) |
0857T |
Opto-acoustic imaging, breast, unilateral, including axilla when performed, realtime with image documentation, augmentative analysis and report (List separately in addition to code for primary procedure) ►(Use 0857T in conjunction with 76641, 76642)◄ |
0865T |
Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion identification, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the brain during the same session ▶(Do not report 0865T in conjunction with 70551, 70552, 70553)◀ |
0866T |
Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion detection, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the brain (List separately in addition to code for primary procedure) ▶(Use 0866T in conjunction with 70551, 70552, 70553)◀ |
36837 |
Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation |
E3000 |
Speech volume modulation system, any type, including all components and accessories |
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:
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:
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.