HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-82-042
Topic:
Intra-Arterial/Intravenous Therapeutic Procedures
Section:
Surgery
Effective Date:
October 8, 2018
Issued Date:
October 8, 2018
Last Revision Date:
October 2018
Annual Review:
October 2018
 
 

Vascular surgery involves a traditional surgical approach and a minimally invasive catheter based endovascular approach. These endovascular procedures insert catheters into small incisions in the groin or arms, and are guided through the blood vessels. Endovascular procedures typically have a quicker recovery time and individuals are able to leave the hospital sooner than the traditional open surgical route.

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

The following intra-arterial/intravenous therapeutic procedures may be considered medically necessary:

  • Transcatheter thrombolytic therapy; or
  • Transcatheter placement of intravascular stents.

37211

37212

37213

37214

37236

37237

37238

37239

 

 

 

 

 

 



Arterial percutaneous transluminal angioplasty (PTA) may be considered medically necessary in the treatment of the following obstructions:

  • Aorta; or
  • Brachiocephalic arteries; or
  • Renal/visceral arteries.

Pre- and post-injections and selective catheter placement for angiography are eligible for separate payment in accordance with multiple surgery guidelines.

36901

36902

36903

36904

36905

36907

36908

36909

37246

37247

37248

37249

 

 


Pulmonary PTA may be considered medically necessary for the treatment of obstructions in the pulmonary arteries. In addition, cardiac catheterization and pre- and post-injections for angiographic studies are eligible for separate payment in accordance with multiple surgery guidelines.

92997

92998

 

 

 

 

 


Venous PTA may be considered medically necessary for the treatment of ANY ONE of the following conditions:

  • On renal patients who have peripheral arterial/venous fistulas for dialysis; or
  • When performed on renal patients who have a centrally placed catheter, i.e., subclavian, jugular, or femoral for dialysis; or
  • When performed for superior vena cava obstruction from benign and malignant diseases; or
  • For central vein stenosis in association with indwelling intravascular devices used for long-term venous access such as central catheters or pic lines; or
  • For iliac compression syndrome (for example, May-Thurner Syndrome).  

Pre- and post-injections and selective catheter placement for angiographic studies are eligible for separate payment in accordance with multiple surgery guidelines. 

Venous angioplasty when used to remove deep vein thrombosis (DVT) is not considered medically necessary.

36902

36905

36906

36907

37239

37246

37247

37248

37249

 

 

 

 

 


Laser angioplasty for non-coronary vessels is considered experimental/investigational and therefore, non-covered, because scientific evidence does not demonstrate the effectiveness of this procedure.

C1725

C1874

C1876

C1885

C2625

 

 

 



Covered Diagnosis codes for procedures codes 37246, 37247, 37248 and 37249

I12.0

I13.11

I13.2

I87.1

N17.0

N17.1

N17.2

N17.8

N17.9

N18.1

N18.2

N18.3

N18.4

N18.5

N18.6

N18.9

N19

T82.49XD

T82.818A

T82.828A

T82.838A

T82.848A

T82.858A

T82.858D

T82.868A

T82.898A

T82.898D

T82.898S

T82.9XXA

 

 

 

 

 

 


Place of Service: Inpatient/Outpatient

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

An intra-arterial/intravenous therapeutic procedure 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.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree 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.