X-52-016

HIGHMARK MEDICARE ADVANTAGE MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

X-52-016

Topic:

Non-Vascular Extremity Ultrasound

Section:

Radiology

Effective Date:

December 31, 2020

Issued Date:

September 27, 2021

Last Revision Date:

September 2021

Ultrasound (US) of the extremity is a non-invasive imaging technique that uses high-frequency sound waves to evaluate the extremities (arms and legs including shoulders, hips, hands and feet), providing real-time, two (2)-dimensional images.

Policy Position

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.

76881

76882

D19.7	D21.11	D21.12	D21.21	D21.22	D36.12	D36.13
D48.1	D48.2	D48.7	G56.01	G56.02	G56.03	G56.21
G56.22	G56.23	G57.11	G57.12	G57.13	G57.21	G57.22
G57.23	G57.31	G57.32	G57.33	G57.41	G57.42	G57.43
G57.51	G57.52	G57.53	I97.630	L40.51	L40.52	L40.53
L40.54	L40.59	M02.011	M02.012	M02.021	M02.022	M02.031
M02.032	M02.041	M02.042	M02.051	M02.052	M02.061	M02.062
M02.071	M02.072	M02.111	M02.112	M02.121	M02.122	M02.131
M02.132	M02.141	M02.142	M02.151	M02.152	M02.161	M02.162
M02.171	M02.172	M02.211	M02.212	M02.221	M02.222	M02.231
M02.232	M02.241	M02.242	M02.251	M02.252	M02.261	M02.262
M02.271	M02.272	M02.311	M02.312	M02.321	M02.322	M02.331
M02.332	M02.341	M02.342	M02.351	M02.352	M02.361	M02.362
M02.371	M02.372	M02.811	M02.812	M02.821	M02.822	M02.831
M02.832	M02.841	M02.842	M02.851	M02.852	M02.861	M02.862
M02.871	M02.872	M05.411	M05.412	M05.421	M05.422	M05.431
M05.432	M05.441	M05.442	M05.451	M05.452	M05.461	M05.462
M05.471	M05.472	M05.49	M05.511	M05.512	M05.521	M05.522
M05.531	M05.532	M05.541	M05.542	M05.551	M05.552	M05.561
M05.562	M05.571	M05.572	M05.59	M05.611	M05.612	M05.621
M05.622	M05.631	M05.632	M05.641	M05.642	M05.651	M05.652
M05.661	M05.662	M05.671	M05.672	M05.711	M05.712	M05.721
M05.722	M05.731	M05.732	M05.741	M05.742	M05.751	M05.752
M05.761	M05.762	M05.771	M05.772	M05.79	M06.011	M06.012
M06.021	M06.022	M06.031	M06.032	M06.041	M06.042	M06.051
M06.052	M06.061	M06.062	M06.071	M06.072	M06.09	M06.211
M06.212	M06.221	M06.222	M06.231	M06.232	M06.241	M06.242
M06.251	M06.252	M06.261	M06.262	M06.271	M06.272	M06.29
M06.311	M06.312	M06.321	M06.322	M06.331	M06.332	M06.341
M06.342	M06.351	M06.352	M06.361	M06.362	M06.371	M06.372
M06.39	M07.611	M07.612	M07.621	M07.622	M07.631	M07.632
M07.641	M07.642	M07.651	M07.652	M07.661	M07.662	M07.671
M07.672	M08.1	M08.211	M08.212	M08.221	M08.222	M08.231
M08.232	M08.241	M08.242	M08.251	M08.252	M08.261	M08.262
M08.271	M08.272	M08.411	M08.412	M08.421	M08.422	M08.431
M08.432	M08.441	M08.442	M08.451	M08.452	M08.461	M08.462
M08.471	M08.472	M10.011	M10.012	M10.021	M10.022	M10.031
M10.032	M10.041	M10.042	M10.051	M10.052	M10.061	M10.062
M10.071	M10.072	M10.09	M10.111	M10.112	M10.121	M10.122
M10.131	M10.132	M10.141	M10.142	M10.151	M10.152	M10.161
M10.162	M10.171	M10.172	M10.19	M10.211	M10.212	M10.221
M10.222	M10.231	M10.232	M10.241	M10.242	M10.251	M10.252
M10.261	M10.262	M10.271	M10.272	M10.29	M11.011	M11.012
M11.021	M11.022	M11.031	M11.032	M11.041	M11.042	M11.051
M11.052	M11.061	M11.062	M11.071	M11.072	M11.111	M11.112
M11.121	M11.122	M11.131	M11.132	M11.141	M11.142	M11.151
M11.152	M11.161	M11.162	M11.171	M11.172	M11.211	M11.212
M11.221	M11.222	M11.231	M11.232	M11.241	M11.242	M11.251
M11.252	M11.261	M11.262	M11.271	M11.272	M11.811	M11.812
M11.821	M11.822	M11.831	M11.832	M11.841	M11.842	M11.851
M11.852	M11.861	M11.862	M11.871	M11.872	M12.011	M12.012
M12.021	M12.022	M12.031	M12.032	M12.041	M12.042	M12.051
M12.052	M12.061	M12.062	M12.071	M12.072	M12.111	M12.112
M12.121	M12.122	M12.131	M12.132	M12.141	M12.142	M12.151
M12.152	M12.161	M12.162	M12.171	M12.172	M12.311	M12.312
M12.321	M12.322	M12.331	M12.332	M12.341	M12.342	M12.351
M12.352	M12.361	M12.362	M12.371	M12.372	M12.511	M12.512
M12.521	M12.522	M12.531	M12.532	M12.541	M12.542	M12.551
M12.552	M12.561	M12.562	M12.571	M12.572	M16.0	M16.11
M16.12	M16.2	M16.31	M16.32	M16.4	M16.51	M16.52
M17.0	M17.11	M17.12	M19.011	M19.012	M19.021	M19.022
M19.031	M19.032	M19.041	M19.042	M19.071	M19.072	M1A.0110
M1A.0111	M1A.0120	M1A.0121	M1A.0210	M1A.0211	M1A.0220	M1A.0221
M1A.0310	M1A.0311	M1A.0320	M1A.0321	M1A.0410	M1A.0411	M1A.0420
M1A.0421	M1A.0510	M1A.0511	M1A.0520	M1A.0521	M1A.0610	M1A.0611
M1A.0620	M1A.0621	M1A.0710	M1A.0711	M1A.0720	M1A.0721	M1A.09X0
M1A.09X1	M1A.2110	M1A.2111	M1A.2120	M1A.2121	M1A.2210	M1A.2211
M1A.2220	M1A.2221	M1A.2310	M1A.2311	M1A.2320	M1A.2321	M1A.2410
M1A.2411	M1A.2420	M1A.2421	M1A.2510	M1A.2511	M1A.2520	M1A.2521
M1A.2610	M1A.2611	M1A.2620	M1A.2621	M1A.2710	M1A.2711	M1A.2720
M1A.2721	M1A.29X0	M1A.29X1	M1A.3110	M1A.3111	M1A.3120	M1A.3121
M1A.3210	M1A.3211	M1A.3220	M1A.3221	M1A.3310	M1A.3311	M1A.3320
M1A.3321	M1A.3410	M1A.3411	M1A.3420	M1A.3421	M1A.3510	M1A.3511
M1A.3520	M1A.3521	M1A.3610	M1A.3611	M1A.3620	M1A.3621	M1A.3710
M1A.3711	M1A.3720	M1A.3721	M1A.39X0	M1A.39X1	M1A.4110	M1A.4111
M1A.4120	M1A.4121	M1A.4210	M1A.4211	M1A.4220	M1A.4221	M1A.4310
M1A.4311	M1A.4320	M1A.4321	M1A.4410	M1A.4411	M1A.4420	M1A.4421
M1A.4510	M1A.4511	M1A.4520	M1A.4521	M1A.4610	M1A.4611	M1A.4620
M1A.4621	M1A.4710	M1A.4711	M1A.4720	M1A.4721	M1A.49X0	M1A.49X1
M24.421	M24.422	M24.431	M24.432	M24.441	M24.442	M24.451
M24.452	M24.461	M24.462	M24.471	M24.472	M24.474	M24.475
M24.511	M24.512	M24.521	M24.522	M24.531	M24.532	M24.541
M24.542	M24.551	M24.552	M24.561	M24.562	M24.571	M24.572
M24.574	M24.575	M24.851	M24.852	M24.871	M24.872	M25.011
M25.012	M25.021	M25.022	M25.031	M25.032	M25.041	M25.042
M25.051	M25.052	M25.061	M25.062	M25.071	M25.072	M25.074
M25.075	M25.411	M25.412	M25.421	M25.422	M25.431	M25.432
M25.441	M25.442	M25.451	M25.452	M25.461	M25.462	M25.471
M25.472	M25.474	M25.475	M25.511	M25.512	M25.521	M25.522
M25.531	M25.532	M25.541	M25.542	M25.551	M25.552	M25.561
M25.562	M25.571	M25.572	M25.731	M25.732	M25.741	M25.742
M25.751	M25.752	M25.761	M25.762	M33.11	M33.12	M33.19
M33.21	M33.22	M33.29	M34.0	M34.89	M35.1	M35.3
M35.4	M35.89	M60.011	M60.012	M60.021	M60.022	M60.031
M60.032	M60.041	M60.042	M60.044	M60.045	M60.051	M60.052
M60.061	M60.062	M60.070	M60.071	M60.073	M60.074	M60.076
M60.077	M60.111	M60.112	M60.121	M60.122	M60.131	M60.132
M60.141	M60.142	M60.151	M60.152	M60.161	M60.162	M60.171
M60.172	M60.211	M60.212	M60.221	M60.222	M60.231	M60.232
M60.241	M60.242	M60.251	M60.252	M60.261	M60.262	M60.271
M60.272	M60.28	M60.811	M60.812	M60.821	M60.822	M60.831
M60.832	M60.841	M60.842	M60.851	M60.852	M60.861	M60.862
M60.871	M60.872	M62.211	M62.212	M62.221	M62.222	M62.231
M62.232	M62.241	M62.242	M62.251	M62.252	M62.261	M62.262
M62.271	M62.272	M62.89	M65.111	M65.112	M65.121	M65.122
M65.131	M65.132	M65.141	M65.142	M65.151	M65.152	M65.161
M65.162	M65.171	M65.172	M65.19	M65.811	M65.812	M65.821
M65.822	M65.831	M65.832	M65.841	M65.842	M65.851	M65.852
M65.861	M65.862	M65.871	M65.872	M65.89	M66.0	M66.111
M66.112	M66.121	M66.122	M66.131	M66.132	M66.141	M66.142
M66.151	M66.152	M66.171	M66.172	M66.174	M66.175	M66.211
M66.212	M66.221	M66.222	M66.231	M66.232	M66.241	M66.242
M66.251	M66.252	M66.261	M66.262	M66.271	M66.272	M66.29
M66.311	M66.312	M66.321	M66.322	M66.331	M66.332	M66.341
M66.342	M66.351	M66.352	M66.361	M66.362	M66.371	M66.372
M66.39	M66.811	M66.812	M66.821	M66.822	M66.831	M66.832
M66.841	M66.842	M66.851	M66.852	M66.861	M66.862	M66.871
M66.872	M66.89	M67.311	M67.312	M67.321	M67.322	M67.331
M67.332	M67.341	M67.342	M67.351	M67.352	M67.361	M67.362
M67.371	M67.372	M67.39	M70.11	M70.12	M70.21	M70.22
M70.31	M70.32	M70.41	M70.42	M70.51	M70.52	M70.61
M70.62	M70.71	M70.72	M70.811	M70.812	M70.821	M70.822
M70.831	M70.832	M70.841	M70.842	M70.851	M70.852	M70.861
M70.862	M70.871	M70.872	M70.89	M71.111	M71.112	M71.121
M71.122	M71.131	M71.132	M71.141	M71.142	M71.151	M71.152
M71.161	M71.162	M71.171	M71.172	M71.19	M71.21	M71.22
M71.311	M71.312	M71.321	M71.322	M71.331	M71.332	M71.341
M71.342	M71.351	M71.352	M71.371	M71.372	M71.39	M71.521
M71.522	M71.531	M71.532	M71.541	M71.542	M71.551	M71.552
M71.561	M71.562	M71.571	M71.572	M75.111	M75.112	M75.121
M75.122	M75.21	M75.22	M75.31	M75.32	M75.51	M75.52
M75.81	M75.82	M76.01	M76.02	M76.11	M76.12	M76.21
M76.22	M76.31	M76.32	M76.41	M76.42	M76.51	M76.52
M76.61	M76.62	M76.71	M76.72	M76.811	M76.812	M76.821
M76.822	M77.01	M77.02	M77.11	M77.12	M77.21	M77.22
M77.51	M77.52	M79.5	M79.601	M79.602	M79.604	M79.605
M79.621	M79.622	M79.631	M79.632	M79.641	M79.642	M79.644
M79.645	M79.651	M79.652	M79.661	M79.662	M79.671	M79.672
M79.674	M79.675	M79.81	M79.89	M84.311A	M84.311D	M84.311G
M84.311K	M84.311P	M84.311S	M84.312A	M84.312D	M84.312G	M84.312K
M84.312P	M84.312S	M84.321A	M84.321D	M84.321G	M84.321K	M84.321P
M84.321S	M84.322A	M84.322D	M84.322G	M84.322K	M84.322P	M84.322S
M84.331A	M84.331D	M84.331G	M84.331K	M84.331P	M84.331S	M84.332A
M84.332D	M84.332G	M84.332K	M84.332P	M84.332S	M84.333A	M84.333D
M84.333G	M84.333K	M84.333P	M84.333S	M84.334A	M84.334D	M84.334G
M84.334K	M84.334P	M84.334S	M84.341A	M84.341D	M84.341G	M84.341K
M84.341P	M84.341S	M84.342A	M84.342D	M84.342G	M84.342K	M84.342P
M84.342S	M84.371A	M84.371D	M84.371G	M84.371K	M84.371P	M84.371S
M84.372A	M84.372D	M84.372G	M84.372K	M84.372P	M84.372S	M84.374A
M84.374D	M84.374G	M84.374K	M84.374P	M84.374S	M84.375A	M84.375D
M84.375G	M84.375K	M84.375P	M84.375S	M96.810	M96.811	M96.830
M96.831	M96.840	M96.841	R22.31	R22.32	R22.33	R22.41
R22.42	R22.43	R29.4	R59.0	R59.1	S43.421A	S43.421D
S43.421S	S43.422A	S43.422D	S43.422S	S43.491A	S43.491D	S43.491S
S43.492A	S43.492D	S43.492S	S43.81XA	S43.81XD	S43.81XS	S43.82XA
S43.82XD	S43.82XS	S46.011A	S46.011D	S46.011S	S46.012A	S46.012D
S46.012S	S46.091A	S46.091D	S46.091S	S46.092A	S46.092D	S46.092S
S46.111A	S46.111D	S46.111S	S46.112A	S46.112D	S46.112S	S46.191A
S46.191D	S46.191S	S46.192A	S46.192D	S46.192S	S46.211A	S46.211D
S46.211S	S46.212A	S46.212D	S46.212S	S46.291A	S46.291D	S46.291S
S46.292A	S46.292D	S46.292S	S46.311A	S46.311D	S46.311S	S46.312A
S46.312D	S46.312S	S46.391A	S46.391D	S46.391S	S46.392A	S46.392D
S46.392S	S46.811A	S46.811D	S46.811S	S46.812A	S46.812D	S46.812S
S46.891A	S46.891D	S46.891S	S46.892A	S46.892D	S46.892S	S49.81XA
S49.81XD	S49.81XS	S49.82XA	S49.82XD	S49.82XS	S53.21XA	S53.21XD
S53.21XS	S53.22XA	S53.22XD	S53.22XS	S53.31XA	S53.31XD	S53.31XS
S53.32XA	S53.32XD	S53.32XS	S53.431A	S53.431D	S53.431S	S53.432A
S53.432D	S53.432S	S53.441A	S53.441D	S53.441S	S53.442A	S53.442D
S53.442S	S53.491A	S53.491D	S53.491S	S53.492A	S53.492D	S53.492S
S56.011A	S56.011D	S56.011S	S56.012A	S56.012D	S56.012S	S56.091A
S56.091D	S56.091S	S56.092A	S56.092D	S56.092S	S56.111A	S56.111D
S56.111S	S56.112A	S56.112D	S56.112S	S56.113A	S56.113D	S56.113S
S56.114A	S56.114D	S56.114S	S56.115A	S56.115D	S56.115S	S56.116A
S56.116D	S56.116S	S56.117A	S56.117D	S56.117S	S56.118A	S56.118D
S56.118S	S56.191A	S56.191D	S56.191S	S56.192A	S56.192D	S56.192S
S56.193A	S56.193D	S56.193S	S56.194A	S56.194D	S56.194S	S56.195A
S56.195D	S56.195S	S56.196A	S56.196D	S56.196S	S56.197A	S56.197D
S56.197S	S56.198A	S56.198D	S56.198S	S56.211A	S56.211D	S56.211S
S56.212A	S56.212D	S56.212S	S56.291A	S56.291D	S56.291S	S56.292A
S56.292D	S56.292S	S56.311A	S56.311D	S56.311S	S56.312A	S56.312D
S56.312S	S56.391A	S56.391D	S56.391S	S56.392A	S56.392D	S56.392S
S56.411A	S56.411D	S56.411S	S56.412A	S56.412D	S56.412S	S56.413A
S56.413D	S56.413S	S56.414A	S56.414D	S56.414S	S56.415A	S56.415D
S56.415S	S56.416A	S56.416D	S56.416S	S56.417A	S56.417D	S56.417S
S56.418A	S56.418D	S56.418S	S56.491A	S56.491D	S56.491S	S56.492A
S56.492D	S56.492S	S56.493A	S56.493D	S56.493S	S56.494A	S56.494D
S56.494S	S56.495A	S56.495D	S56.495S	S56.496A	S56.496D	S56.496S
S56.497A	S56.497D	S56.497S	S56.498A	S56.498D	S56.498S	S56.511A
S56.511D	S56.511S	S56.512A	S56.512D	S56.512S	S56.591A	S56.591D
S56.591S	S56.592A	S56.592D	S56.592S	S56.811A	S56.811D	S56.811S
S56.812A	S56.812D	S56.812S	S56.891A	S56.891D	S56.891S	S56.892A
S56.892D	S56.892S	S59.801A	S59.801D	S59.801S	S59.802A	S59.802D
S59.802S	S59.811A	S59.811D	S59.811S	S59.812A	S59.812D	S59.812S
S63.311A	S63.311D	S63.311S	S63.312A	S63.312D	S63.312S	S63.321A
S63.321D	S63.321S	S63.322A	S63.322D	S63.322S	S63.331A	S63.331D
S63.331S	S63.332A	S63.332D	S63.332S	S63.391A	S63.391D	S63.391S
S63.392A	S63.392D	S63.392S	S63.511A	S63.511D	S63.511S	S63.512A
S63.512D	S63.512S	S63.521A	S63.521D	S63.521S	S63.522A	S63.522D
S63.522S	S63.591A	S63.591D	S63.591S	S63.592A	S63.592D	S63.592S
S63.8X1A	S63.8X1D	S63.8X1S	S63.8X2A	S63.8X2D	S63.8X2S	S66.011A
S66.011D	S66.011S	S66.012A	S66.012D	S66.012S	S66.091A	S66.091D
S66.091S	S66.092A	S66.092D	S66.092S	S66.110A	S66.110D	S66.110S
S66.111A	S66.111D	S66.111S	S66.112A	S66.112D	S66.112S	S66.113A
S66.113D	S66.113S	S66.114A	S66.114D	S66.114S	S66.115A	S66.115D
S66.115S	S66.116A	S66.116D	S66.116S	S66.117A	S66.117D	S66.117S
S66.190A	S66.190D	S66.190S	S66.191A	S66.191D	S66.191S	S66.192A
S66.192D	S66.192S	S66.193A	S66.193D	S66.193S	S66.194A	S66.194D
S66.194S	S66.195A	S66.195D	S66.195S	S66.196A	S66.196D	S66.196S
S66.197A	S66.197D	S66.197S	S66.211A	S66.211D	S66.211S	S66.212A
S66.212D	S66.212S	S66.291A	S66.291D	S66.291S	S66.292A	S66.292D
S66.292S	S66.310A	S66.310D	S66.310S	S66.311A	S66.311D	S66.311S
S66.312A	S66.312D	S66.312S	S66.313A	S66.313D	S66.313S	S66.314A
S66.314D	S66.314S	S66.315A	S66.315D	S66.315S	S66.316A	S66.316D
S66.316S	S66.317A	S66.317D	S66.317S	S66.390A	S66.390D	S66.390S
S66.391A	S66.391D	S66.391S	S66.392A	S66.392D	S66.392S	S66.393A
S66.393D	S66.393S	S66.394A	S66.394D	S66.394S	S66.395A	S66.395D
S66.395S	S66.396A	S66.396D	S66.396S	S66.397A	S66.397D	S66.397S
S66.411A	S66.411D	S66.411S	S66.412A	S66.412D	S66.412S	S66.491A
S66.491D	S66.491S	S66.492A	S66.492D	S66.492S	S66.510A	S66.510D
S66.510S	S66.511A	S66.511D	S66.511S	S66.512A	S66.512D	S66.512S
S66.513A	S66.513D	S66.513S	S66.514A	S66.514D	S66.514S	S66.515A
S66.515D	S66.515S	S66.516A	S66.516D	S66.516S	S66.517A	S66.517D
S66.517S	S66.590A	S66.590D	S66.590S	S66.591A	S66.591D	S66.591S
S66.592A	S66.592D	S66.592S	S66.593A	S66.593D	S66.593S	S66.594A
S66.594D	S66.594S	S66.595A	S66.595D	S66.595S	S66.596A	S66.596D
S66.596S	S66.597A	S66.597D	S66.597S	S66.811A	S66.811D	S66.811S
S66.812A	S66.812D	S66.812S	S66.891A	S66.891D	S66.891S	S66.892A
S66.892D	S66.892S	S69.81XA	S69.81XD	S69.81XS	S69.82XA	S69.82XD
S69.82XS	S73.041A	S73.041D	S73.041S	S73.042A	S73.042D	S73.042S
S73.044A	S73.044D	S73.044S	S73.045A	S73.045D	S73.045S	S73.191A
S73.191D	S73.191S	S73.192A	S73.192D	S73.192S	S76.011A	S76.011D
S76.011S	S76.012A	S76.012D	S76.012S	S76.091A	S76.091D	S76.091S
S76.092A	S76.092D	S76.092S	S76.111A	S76.111D	S76.111S	S76.112A
S76.112D	S76.112S	S76.191A	S76.191D	S76.191S	S76.192A	S76.192D
S76.192S	S76.211A	S76.211D	S76.211S	S76.212A	S76.212D	S76.212S
S76.291A	S76.291D	S76.291S	S76.292A	S76.292D	S76.292S	S76.311A
S76.311D	S76.311S	S76.312A	S76.312D	S76.312S	S76.391A	S76.391D
S76.391S	S76.392A	S76.392D	S76.392S	S76.811A	S76.811D	S76.811S
S76.812A	S76.812D	S76.812S	S76.891A	S76.891D	S76.891S	S76.892A
S76.892D	S76.892S	S79.811A	S79.811D	S79.811S	S79.812A	S79.812D
S79.812S	S79.821A	S79.821D	S79.821S	S79.822A	S79.822D	S79.822S
S83.411A	S83.411D	S83.411S	S83.412A	S83.412D	S83.412S	S83.421A
S83.421D	S83.421S	S83.422A	S83.422D	S83.422S	S83.61XA	S83.61XD
S83.61XS	S83.62XA	S83.62XD	S83.62XS	S83.8X1A	S83.8X1D	S83.8X1S
S83.8X2A	S83.8X2D	S83.8X2S	S86.011A	S86.011D	S86.011S	S86.012A
S86.012D	S86.012S	S86.091A	S86.091D	S86.091S	S86.092A	S86.092D
S86.092S	S86.111A	S86.111D	S86.111S	S86.112A	S86.112D	S86.112S
S86.191A	S86.191D	S86.191S	S86.192A	S86.192D	S86.192S	S86.211A
S86.211D	S86.211S	S86.212A	S86.212D	S86.212S	S86.291A	S86.291D
S86.291S	S86.292A	S86.292D	S86.292S	S86.311A	S86.311D	S86.311S
S86.312A	S86.312D	S86.312S	S86.391A	S86.391D	S86.391S	S86.392A
S86.392D	S86.392S	S86.811A	S86.811D	S86.811S	S86.812A	S86.812D
S86.812S	S86.891A	S86.891D	S86.891S	S86.892A	S86.892D	S86.892S
S89.81XA	S89.81XD	S89.81XS	S89.82XA	S89.82XD	S89.82XS	S93.411A
S93.411D	S93.411S	S93.412A	S93.412D	S93.412S	S93.421A	S93.421D
S93.421S	S93.422A	S93.422D	S93.422S	S93.431A	S93.431D	S93.431S
S93.432A	S93.432D	S93.432S	S93.491A	S93.491D	S93.491S	S93.492A
S93.492D	S93.492S	S93.611A	S93.611D	S93.611S	S93.612A	S93.612D
S93.612S	S93.621A	S93.621D	S93.621S	S93.622A	S93.622D	S93.622S
S93.691A	S93.691D	S93.691S	S93.692A	S93.692D	S93.692S	S96.011A
S96.011D	S96.011S	S96.012A	S96.012D	S96.012S	S96.091A	S96.091D
S96.091S	S96.092A	S96.092D	S96.092S	S96.111A	S96.111D	S96.111S
S96.112A	S96.112D	S96.112S	S96.191A	S96.191D	S96.191S	S96.192A
S96.192D	S96.192S	S96.211A	S96.211D	S96.211S	S96.212A	S96.212D
S96.212S	S96.291A	S96.291D	S96.291S	S96.292A	S96.292D	S96.292S
S96.811A	S96.811D	S96.811S	S96.812A	S96.812D	S96.812S	S96.891A
S96.891D	S96.891S	S96.892A	S96.892D	S96.892S	S99.811A	S99.811D
S99.811S	S99.812A	S99.812D	S99.812S	S99.821A	S99.821D	S99.821S
S99.822A	S99.822D	S99.822S	T84.51XA	T84.51XD	T84.51XS	T84.52XA
T84.52XD	T84.52XS	T84.53XA	T84.53XD	T84.53XS	T84.54XA	T84.54XD
T84.54XS	T84.59XA	T84.59XD	T84.59XS	T84.610A	T84.610D	T84.610S
T84.611A	T84.611D	T84.611S	T84.612A	T84.612D	T84.612S	T84.613A
T84.613D	T84.613S	T84.614A	T84.614D	T84.614S	T84.615A	T84.615D
T84.615S	T84.620A	T84.620D	T84.620S	T84.621A	T84.621D	T84.621S
T84.622A	T84.622D	T84.622S	T84.623A	T84.623D	T84.623S	T84.624A
T84.624D	T84.624S	T84.625A	T84.625D	T84.625S	T84.7XXA	T84.7XXD
T84.7XXS	T87.41	T87.42	T87.43	T87.44

Related Policies

Refer to Medicare Advantage medical policy M-79 Independent Diagnostic Testing Facility for additional information.

Refer to Medicare Advantage medical policy N-83 Ultrasound Diagnostic Procedures - NCD 220.5 for additional information.

The policy position applies to all Medicare Advantage lines of business

Links

CMS Links

CMS Website

Article Links

Article Link

LCD Links

LCD Link

References

Novitas Solutions, Inc., LCD L35409. Revised 10/17/2019 (R11).
Novitas Solutions, Inc., LCA A55037. Revised 01/01/2021 (R4).

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, and subject to the applicable laws of your state.

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.