HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
R-101-002
Topic:
Hepatobiliary System Imaging
Section:
Radiation Therapy & Nuclear Medicine
Effective Date:
October 1, 2023
Issued Date:
October 1, 2023
Last Revision Date:
September 2023
Annual Review:
January 2023
 
 

A Hepatobiliary System Imaging (HIDA) scan is an imaging study to diagnose problems with the liver, gallbladder, and bile ducts. The scan is often utilized when an ultrasound is inconclusive in determining the cause of biliary symptoms. A HIDA scan can be performed with or without cholecystokinin (CCK).

Policy Position

HIDA without CCK

HIDA scan without CCK may be considered medically necessary if ANY of the following is met:

  • If there is right upper quadrant pain or epigastric pain and there is a suspicion of gallbladder disease, with a normal, or equivocal or non-diagnostic recent ultrasound; or
  • Suspected bile leak after trauma or surgery; or
  • Monitoring of liver regeneration; or
  • Assessment of liver transplant; or
  • Assessment of choledochal cyst; or
  • Pre-operative assessment prior to partial hepatectomy; or
  • Chronic acalculous cholecystitis, biliary dyskinesia, functional gallbladder disease, or sphincter of Oddi dysfunction.

HIDA without CCK not meeting the criteria as indicated in this policy is considered not medically necessary. 

78226

 

 

 

 

 

 




HIDA with CCK

HIDA scan with CCK may be considered medically necessary if ANY ONE of the following is met:

  • If there is right upper quadrant pain or epigastric pain with a normal, or equivocal or non-diagnostic recent ultrasound, and no known diagnosis of cholelithiasis; or
  • Chronic acalculous cholecystitis, biliary dyskinesia, functional gallbladder disease, or sphincter of Oddi dysfunction.

HIDA scan with CCK not meeting the criteria as indicated in this policy is considered not medically necessary. 

78227

 

 

 

 

 

 




Covered diagnosis codes for procedure codes 78226, 78227

C23

C24.0

C24.1

C24.8

C24.9

C78.89  

D01.5  

D13.5  

D37.6  

D49.0  

K80.00

K80.01

K80.10

K80.11

K80.12

K80.13

K80.18

K80.19

K80.20

K80.21

K80.30 

K80.31

K80.32 

K80.33

K80.34

K80.35

K80.36

K80.37 

K80.40

K80.41

K80.42

K80.43

K80.44

K80.45

K80.46

K80.47

K80.50

K80.51

K80.60

K80.61

K80.62

K80.63

K80.64

K80.65

K80.66

K80.67 

K80.70

K80.71

K80.80

K80.81

K81.0

K81.1

K81.2

K81.9

K82.0

K82.1

K82.2

K82.3

K82.4

K82.8

K82.9

K82.A1

K82.A2

K83.01

K83.09

K83.1

K83.2

K83.3

K83.4

K83.5

K83.8

K83.9

K87

K91.5

K91.61

K91.62 

K91.71

K91.72

K91.81

K91.82

K91.83

K91.840

K91.841

Q44.0

Q44.1

Q44.2

Q44.3

Q44.4

Q44.5

Q44.70

Q44.71

Q44.79

S36.122A

S36.122D

S36.122S

S36.123A

S36.123D

S36.123S

S36.128A

S36.128D

S36.128S

S36.129A

S36.129D

S36.129S

S36.13XA

S36.13XD

S36.13XS

T86.40

T86.41

T86.42

T86.43

T86.49

Z48.23  

Z94.4   

 

 

 

 

 



Place of Service: Inpatient/Outpatient

HIDA scan with or without CCK 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



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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.

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:

  • 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.