HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
V-44-019
Topic:
Medical Nutrition Management Services (MNT)
Section:
Visits
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
February 2017
Annual Review:
February 2017
 
 

Medical Nutrition Therapy (MNT) is an important part of prevention and treatment of many diseases and conditions. MNT is the assessment of the individual’s nutritional status followed by therapy. The overall goal of MNT is to assist the individual in making changes in nutrition and exercise habits leading to improved health through optimal nutrition.

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

MNT is covered for certain conditions listed below. This list includes those diagnoses/conditions that commonly benefit from MNT in improving desired health outcomes. (This is not intended to be an all-inclusive list.)

  • Human immunodeficiency virus (HIV) disease
  • Secondary diabetes mellitus
  • Diabetes mellitus
  • Nutritional deficiencies
  • Disorders of amino-acid transport and metabolism
  • Disorders of lipid metabolism
  • Disorders of mineral and calcium metabolism
  • Hyponatremia
  • Hyperpotassemia
  • Hypopotassemia
  • Cystic fibrosis
  • Other specified disorders of metabolism
  • Morbid obesity
  • Anorexia nervosa and eating disorders
  • Epilepsy and other convulsive disorder
  • Hypertensive disease
  • Ischemic heart disease
  • Chronic pulmonary heart disease
  • Cardiomyopathy
  • Heart failure
  • Myocarditis
  • Myocardial degeneration
  • Cardiovascular disease
  • Cardiomegaly
  • Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and duodenitis
  • Disorders of function of stomach and gastrostomy complications and other disorders of stomach and duodenum
  • Regional enteritis, ulcerative colitis, vascular insufficiency of intestine, other and unspecified noninfectious gastroenteritis and colitis, intestinal obstruction, diverticula of intestine, and functional digestive disorders
  • Colostomy and enterostomy complications, and other specified disorders of the intestines
  • Liver diseases, cirrhosis, and other diseases of the digestive system
  • Glomerulonephritis, nephrotic syndrome, nephritis, renal failure, infections of kidney, calculus of kidney and ureter, and disorder of bladder
  • Hypertension complicating pregnancy, childbirth, and the puerperium
  • Gestational diabetes
  • Osteoporosis
  • Congenital anomalies of the digestive system
  • Congenital anomalies of kidney
  • Symptoms concerning nutrition, metabolism and development. 

MNT may be covered for the management of obesity.  

97802

97803

97804

G0270

G0271


When reported separately, charges for MNT should be combined with and processed under the appropriate medical visit procedure codes. If MNT is the only service performed, it will be reimbursed in accordance with the member's medical care benefits. Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

When the 25 modifier is reported, the patient's records must clearly document that separately identifiable medical care has been rendered.

Related Policies

Refer to medical policy Z-27 Eligible Providers and Supervision Guidelines for additional information.

Refer to medical policy G-24 Obesity for additional information. 

Refer to medical policy E-15 Diabetic Services and Supplies for additional information. 

Refer to medical policy V-37 Autism Spectrum Disorders for additional information.


Covered diagnosis Codes for procedure codes 97802, 97803, 97804, G0270, G0271

A18.84

A56.01

B20

B25.1

B25.2

B52.0

C96.5

C96.6

D81.818

D81.819

E08 37X2

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3219

E08.3291

E08.3292

E08.3293

E08.3299

E08.3311

E08.3312

E08.3313

E08.3319

E08.3391

E08.3392

E08.3393

E08.3399

E08.3411

E08.3412

E08.3413

E08.3419

E08.3491

E08.3492

E08.3493

E08.3499

E08.3511

E08.3512

E08.3513

E08.3519

E08.3591

E08.3592

E08.3593

E08.3599

E08.36

E08.37X1

E08.37X3

E08.37X9

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09 37X2

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3219

E09.3291

E09.3292

E09.3293

E09.3299

E09.3311

E09.3312

E09.3313

E09.3319

E09.3391

E09.3392

E09.3393

E09.3399

E09.3411

E09.3412

E09.3413

E09.3419

E09.3491

E09.3492

E09.3493

E09.3499

E09.3511

E09.3512

E09.3513

E09.3519

E09.3591

E09.3592

E09.3593

E09.3599

E09.36

E09.37X1

E09.37X3

E09.37X9

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10 37X2

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.3219

E10.3291

E10.3292

E10.3293

E10.3299

E10.3311

E10.3312

E10.3313

E10.3319

E10.3391

E10.3392

E10.3393

E10.3399

E10.3411

E10.3412

E10.3413

E10.3419

E10.3491

E10.3492

E10.3493

E10.3499

E10.3511

E10.3512

E10.3513

E10.3519

E10.3591

E10.3592

E10.3593

E10.3599

E10.36

E10.37X1

E10.37X3

E10.37X9

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11 37X2

E11.00

E11.01

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3219

E11.3291

E11.3292

E11.3293

E11.3299

E11.3311

E11.3312

E11.3313

E11.3319

E11.3391

E11.3392

E11.3393

E11.3399

E11.3411

E11.3412

E11.3413

E11.3419

E11.3491

E11.3492

E11.3493

E11.3499

E11.3511

E11.3512

E11.3513

E11.3519

E11.3591

E11.3592

E11.3593

E11.3599

E11.36

E11.37X1

E11.37X3

E11.37X9

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E1110

E1111

E13 37X2

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3219

E13.3291

E13.3292

E13.3293

E13.3299

E13.3311

E13.3312

E13.3313

E13.3319

E13.3391

E13.3392

E13.3393

E13.3399

E13.3411

E13.3412

E13.3413

E13.3419

E13.3491

E13.3492

E13.3493

E13.3499

E13.3511

E13.3512

E13.3513

E13.3519

E13.3591

E13.3592

E13.3593

E13.3599

E13.36

E13.37X1

E13.37X3

E13.37X9

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

E20.1

E40

E41

E42

E43

E44.0

E44.1

E45

E46

E50.0

E50.1

E50.2

E50.3

E50.4

E50.5

E50.6

E50.7

E50.8

E50.9

E51.11

E51.12

E51.2

E51.8

E51.9

E52

E53.0

E53.1

E53.8

E53.9

E54

E55.0

E55.9

E61.9

E63.9

E64.0

E64.1

E64.2

E64.3

E64.9

E66.01

E70.0

E70.1

E70.20

E70.21

E70.29

E70.30

E70.310

E70.311

E70.318

E70.319

E70.320

E70.321

E70.328

E70.329

E70.330

E70.331

E70.338

E70.339

E70.39

E70.40

E70.41

E70.49

E70.5

E70.5

E70.8

E70.8

E70.9

E70.9

E71.0

E71.110

E71.111

E71.118

E71.120

E71.121

E71.128

E71.2

E71.30

E71.310

E71.311

E71.312

E71.313

E71.314

E71.318

E71.32

E71.39

E71.40

E71.41

E71.42

E71.43

E71.440

E71.448

E71.50

E71.510

E71.511

E71.518

E71.520

E71.521

E71.522

E71.528

E71.529

E71.53

E71.540

E71.541

E71.542

E71.548

E72.00

E72.01

E72.02

E72.03

E72.04

E72.09

E72.10

E72.11

E72.12

E72.19

E72.20

E72.21

E72.22

E72.23

E72.29

E72.3

E72.4

E72.50

E72.51

E72.59

E72.8

E72.81

E72.89

E72.9

E75.21

E75.22

E75.240

E75.241

E75.242

E75.243

E75.248

E75.249

E75.26

E75.3

E75.5

E75.6

E77.0

E77.1

E77.8

E77.9

E78.00

E78.1

E78.2

E78.3

E78.4

E78.41

E78.49

E78.5

E78.6

E78.70

E78.79

E78.81

E78.89

E78.9

E80.3

E83.00

E83.01

E83.09

E83.10

E83.110

E83.111

E83.118

E83.119

E83.19

E83.30

E83.31

E83.32

E83.39

E83.40

E83.41

E83.42

E83.49

E83.50

E83.51

E83.52

E83.59

E83.81

E83.89

E83.9

E84.0

E84.11

E84.19

E84.8

E84.9

E87.1

E87.5

E87.6

E88.02

E88.1

E88.2

E88.3

E88.40

E88.41

E88.42

E88.49

E88.89

E88.9

F50.00

F50.01

F50.02

F50.2

F50.81

F50.89

F50.9

F98.21

F98.29

F98.3

G40.001

G40.009

G40.011

G40.019

G40.101

G40.109

G40.111

G40.119

G40.201

G40.209

G40.211

G40.219

G40.301

G40.309

G40.311

G40.319

G40.401

G40.409

G40.411

G40.419

G40.501

G40.509

G40.801

G40.802

G40.803

G40.804

G40.811

G40.812

G40.813

G40.814

G40.821

G40.822

G40.823

G40.824

G40.89

G40.901

G40.909

G40.911

G40.919

G40.A01

G40.A09

G40.A11

G40.A19

G40.B01

G40.B09

G40.B11

G40.B19

H49.811

H49.812

H49.813

H49.819

I10

I11.0

I11.9

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

I20.0

I20.1

I20.8

I20.9

I21.01

I21.02

I21.09

I21.11

I21.19

I21.21

I21.29

I21.3

I21.4

I21.9

I21.A1

I21.A9

I22.0

I22.1

I22.2

I22.8

I22.9

I24.0

I24.1

I24.8

I24.9

I25.10

I25.110

I25.111

I25.118

I25.119

I25.2

I25.3

I25.41

I25.42

I25.5

I25.6

I25.700

I25.701

I25.708

I25.709

I25.710

I25.711

I25.718

I25.719

I25.720

I25.721

I25.728

I25.729

I25.730

I25.731

I25.738

I25.739

I25.750

I25.751

I25.758

I25.759

I25.760

I25.761

I25.768

I25.769

I25.790

I25.791

I25.798

I25.799

I25.810

I25.811

I25.812

I25.89

I25.9

I27.0

I27.1

I27.20

I27.21

I27.22

I27.23

I27.24

I27.29

I27.81

I27.82

I27.83

I27.89

I27.9

I42.0

I42.1

I42.2

I42.3

I42.4

I42.5

I42.6

I42.7

I42.8

I42.9

I43

I50.1

I50.20

I50.21

I50.22

I50.23

I50.30

I50.31

I50.32

I50.33

I50.40

I50.41

I50.42

I50.43

I50.810

I50.811

I50.812

I50.813

I50.814

I50.82

I50.83

I50.84

I50.89

I50.9

I51.4

I51.5

I51.7

K25.0

K25.1

K25.2

K25.3

K25.4

K25.6

K25.7

K25.9

K26.0

K26.1

K26.2

K26.3

K26.4

K26.5

K26.6

K26.7

K26.9

K27.0

K27.1

K27.2

K27.3

K27.4

K27.5

K27.6

K27.7

K27.9

K28.0

K28.1

K28.2

K28.3

K28.4

K28.5

K28.6

K28.7

K28.9

K29.00

K29.01

K29.20

K29.21

K29.30

K29.31

K29.40

K29.41

K29.50

K29.51

K29.60

K29.61

K29.70

K29.71

K29.80

K29.81

K29.90

K29.91

K30

K31.0

K31.1

K31.2

K31.3

K31.4

K31.5

K31.6

K31.811

K31.819

K31.82

K31.83

K31.84

K31.89

K31.9

K35.20

K35.21

K35.30

K35.31

K35.32

K35.33

K35.890

K35.891

K50.00

K50.011

K50.012

K50.013

K50.014

K50.018

K50.019

K50.10

K50.111

K50.112

K50.113

K50.114

K50.118

K50.119

K50.80

K50.811

K50.812

K50.813

K50.814

K50.818

K50.819

K50.90

K50.911

K50.912

K50.913

K50.914

K50.918

K50.919

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.40

K51.411

K51.412

K51.413

K51.414

K51.418

K51.419

K51.50

K51.511

K51.512

K51.513

K51.514

K51.518

K51.519

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.0

K52.1

K52.2

K52.81

K52.82

K52.89

K52.9

K55.1

K55.20

K55.21

K55.8

K55.9

K56.0

K56.1

K56.2

K56.3

K56.41

K56.49

K56.5

K56.50

K56.51

K56.52

K56.600

K56.601

K56.609

K56.690

K56.691

K56.699

K56.7

K57.00

K57.01

K57.10

K57.11

K57.12

K57.13

K57.20

K57.21

K57.30

K57.31

K57.32

K57.33

K57.40

K57.41

K57.50

K57.51

K57.52

K57.53

K57.80

K57.81

K57.90

K57.91

K57.92

K57.93

K58.0

K58.9

K59.00

K59.01

K59.02

K59.09

K59.1

K59.2

K59.3

K59.31

K59.39

K59.4

K59.8

K59.9

K61.31

K61.39

K61.5

K63.1

K63.2

K63.3

K63.4

K63.81

K63.89

K63.9

K70.0

K70.10

K70.11

K70.2

K70.30

K70.31

K70.40

K70.41

K70.9

K71.0

K71.10

K71.11

K71.2

K71.3

K71.4

K71.50

K71.51

K71.6

K71.7

K71.8

K71.9

K72.00

K72.01

K72.10

K72.11

K72.90

K72.91

K73.0

K73.1

K73.2

K73.8

K73.9

K74.0

K74.1

K74.2

K74.3

K74.4

K74.5

K74.60

K74.69

K75.0

K75.1

K75.2

K75.3

K75.4

K75.81

K75.89

K75.9

K76.0

K76.1

K76.2

K76.3

K76.4

K76.5

K76.6

K76.7

K76.81

K76.89

K76.9

K77

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

K81.1

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

K83.9

K85.00

K85.01

K85.02

K85.10

K85.11

K85.12

K85.20

K85.21

K85.22

K85.30

K85.31

K85.32

K85.80

K85.81

K85.82

K85.90

K85.91

K85.92

K86.0

K86.1

K86.2

K86.3

K86.8

K86.9

K87

K90.0

K90.1

K90.2

K90.3

K90.41

K90.89

K91.0

K91.1

K91.2

K91.30

K91.31

K91.32

K91.5

K91.89

K92.0

K92.1

K92.2

K92.89

K92.9

K94.00

K94.01

K94.02

K94.03

K94.09

K94.10

K94.11

K94.12

K94.13

K94.19

K94.20

K94.21

K94.22

K94.23

K94.29

M32.14

M32.15

M35.04

M81.0

M81.6

M81.8

M83.0

M83.1

M83.2

M83.3

M83.4

M83.5

M83.8

M83.9

N00.0

N00.1

N00.2

N00.3

N00.4

N00.5

N00.6

N00.7

N00.8

N00.9

N01.0

N01.1

N01.2

N01.3

N01.4

N01.5

N01.6

N01.7

N01.8

N01.9

N02.0

N02.1

N02.2

N02.3

N02.4

N02.5

N02.6

N02.7

N02.8

N02.9

N03.0

N03.1

N03.2

N03.3

N03.4

N03.5

N03.6

N03.7

N03.8

N03.9

N04.0

N04.1

N04.2

N04.3

N04.4

N04.5

N04.6

N04.7

N04.8

N04.9

N05.0

N05.1

N05.2

N05.3

N05.4

N05.5

N05.6

N05.7

N05.8

N05.9

N06.0

N06.1

N06.2

N06.3

N06.4

N06.5

N06.6

N06.7

N06.8

N06.9

N07.0

N07.1

N07.2

N07.3

N07.4

N07.5

N07.6

N07.7

N07.8

N07.9

N08

N10

N11.0

N11.1

N11.8

N11.9

N12

N13.0

N13.1

N13.2

N13.30

N13.39

N13.4

N13.5

N13.6

N13.70

N13.71

N13.721

N13.722

N13.729

N13.731

N13.732

N13.739

N13.8

N13.9

N14.0

N14.1

N14.2

N14.3

N14.4

N15.0

N15.1

N15.8

N15.9

N16

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

N20.0

N20.1

N20.2

N20.9

N21.0

N21.1

N21.8

N21.9

N22

N25.0

N25.1

N25.81

N25.89

N26.1

N26.9

N27.0

N27.1

N27.9

N28.0

N28.1

N28.81

N28.82

N28.83

N28.84

N28.85

N28.86

N28.89

N28.9

N29

N30.00

N30.01

N30.10

N30.11

N30.20

N30.21

N30.30

N30.31

N30.40

N30.41

N30.80

N30.81

N30.90

N30.91

N31.0

N31.1

N31.2

N31.8

N31.9

N32.0

N32.1

N32.2

N32.3

N32.81

N32.89

N32.9

N33

N34.0

N34.1

N34.2

N34.3

N35.010

N35.011

N35.012

N35.013

N35.014

N35.016

N35.021

N35.028

N35.111

N35.112

N35.113

N35.114

N35.116

N35.119

N35.12

N35.811

N35.812

N35.813

N35.814

N35.816

N35.819

N35.82

N35.911

N35.912

N35.913

N35.914

N35.916

N35.919

N35.92

N36.0

N36.1

N36.2

N36.41

N36.42

N36.43

N36.44

N36.5

N36.8

N36.9

N37

N39.0

N39.9

N99.110

N99.111

N99.112

N99.113

N99.114

N99.116

N99.12

N99.510

N99.511

N99.512

N99.518

O10.011

O10.012

O10.013

O10.019

O10.02

O10.03

O10.111

O10.112

O10.113

O10.119

O10.12

O10.13

O10.211

O10.212

O10.213

O10.219

O10.22

O10.23

O10.311

O10.312

O10.313

O10.319

O10.32

O10.33

O10.411

O10.412

O10.413

O10.419

O10.42

O10.43

O10.911

O10.912

O10.913

O10.919

O10.92

O10.93

O11.1

O11.2

O11.3

O11.9

O13.1

O13.2

O13.3

O13.9

O14.00

O14.02

O14.03

O14.10

O14.12

O14.13

O14.20

O14.22

O14.23

O14.90

O14.92

O14.93

O15.00

O15.02

O15.03

O15.1

O15.2

O15.9

O16.1

O16.2

O16.3

O16.4

O16.5

O16.9

O24.410

O24.414

O24.419

O24.420

O24.424

O24.429

O24.430

O24.434

O24.439

O99.810

O99.814

O99.815

Q41.0

Q41.1

Q41.2

Q41.8

Q41.9

Q42.0

Q42.1

Q42.2

Q42.3

Q42.8

Q42.9

Q43.0

Q43.1

Q43.2

Q43.3

Q43.4

Q43.5

Q43.6

Q43.7

Q43.8

Q43.9

Q44.0

Q44.1

Q44.2

Q44.3

Q44.4

Q44.5

Q44.6

Q44.7

Q45.0

Q45.1

Q45.2

Q45.3

Q45.8

Q45.9

Q60.0

Q60.1

Q60.2

Q60.3

Q60.4

Q60.5

Q60.6

Q61.00

Q61.01

Q61.02

Q61.11

Q61.19

Q61.2

Q61.3

Q61.4

Q61.5

Q61.8

Q61.9

Q62.0

Q62.10

Q62.11

Q62.12

Q62.2

Q62.31

Q62.32

Q62.39

Q63.0

Q63.1

Q63.2

Q63.3

Q63.8

Q63.9

R11.10

R11.13

R31.0

R31.1

R56.9

R62.0

R62.50

R62.51

R62.52

R62.59

R63.0

R63.3

R63.4

R63.5

R63.6

R80.2

Z68.30

Z68.31

Z68.32

Z68.33

Z68.34

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Z68.51

Z68.52

Z68.53

Z68.54

Z71.3

 

 

 

 

 

Non-covered diagnosis codes for procedure codes 97802, 97803, 97804, G0270, G0271

F90.0

F90.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

R53.82

Z68.20

Z68.21

Z68.22

Z68.23

Z68.24

Z68.25

Z68.26

Z68.27

Z68.28

Z68.29

 

 

 

 


Place of Service: Inpatient/Outpatient

MNT 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.



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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.