Policy Updates August 2014

The information outlines updates to policies that are effective this month. To view the updated policy in its entirety, select the policy name.

Policy Name Affected Physicians Updates Effective Date
Acupuncture
  • Acupuncturists
  • Chiropractors
  • Physiatrists
  • Physical medicine physicians
  • Internal medicine physicians
  • CPT® codes 97810, 97811, 97813, and 97814 will have a specific set of diagnosis codes that will be covered when billed together.
  • Claims will be denied as not medically necessary for all customers if the diagnosis and procedure codes billed do not align with covered services defined by the policy.
  • 08/18/2014
Bone Growth Stimulators
  • Neurological surgeons
  • Orthopedic surgeons
  • Requests for a spinal bone growth stimulator for cervical fusion surgery will be denied, as the service is considered experimental, investigational or unproven.
  • Affected codes are HCPCS E0748 and CPT 20975.
  • 08/18/2014
Facility Routine Services and Supplies and Equipment*
  • Anesthesiologists
  • Cardiologists
  • Family practice physicians
  • Gastroenterologists
  • Hematologists
  • Internal medicine physicians
  • OB/GYNs
  • Oncologists
  • Orthopedists
  • Pain management physicians
  • Radiologists
  • Duplicative claims for the following CPT codes associated with routine services and injections will be denied: 96360-96361, 96365-96379, 96401-96402, 96409-96425, 96521-96523, A4206-A9999, E0160-E0642, and E0691-E8002.
  • 08/18/2014
Genetic Testing for Mitochondrial Disorders
  • Family practice physicians
  • Internal medicine physicians
  • Neurologist
  • OB/GYNs
  • Pediatricians
  • Genetic testing will be approved for the use of only eight specific mitochondrial disorders, including:

    Kearns Sayre syndrome; Pearson syndrome; progressive external opthalmoplegia (PEO); Leigh syndrome; neurogenic muscle weakness with ataxia and retinitis pigmentosa (NARP); leber hereditary optic neuropathy (LHON); mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS); and myoclonic epilepsy with ragged red fibers (MERRF)

  • Affected CPT codes are 81401, 81403, 81404, 81405, 81406, and 81479.

  • 08/18/2014
Intraoperative Monitoring*

(Part of Code Editing Guideline)
  • Anesthesiologists
  • Otolaryngologists (ear, nose, and throat specialists)
  • Neurologists
  • Intraoperative neurophysiology monitoring will not be eligible for separate reimbursement when performed and billed by the surgeon (including co-surgeon, assistant surgeon, and team surgeon) or anesthesiologist.
  • This includes codes 95940, 95941 and G0453, which will be denied as incidental when billed in addition to a code from either the code range of 00100 – 01999 or the range of 10021 – 69990.
  • 08/18/2014
Omnibus Codes

(Fecal Calprotectin Testing)
  • Gastroenterologists
  • Internal medicine physicians
  • Family practice physicians
  • Pathologists
  • Pediatricians
  • Fecal calprotectin testing (CPT code 83993) will not be covered, as it is considered experimental, investigational or unproven.
  • 08/18/2014
Helicobacter Pylori (H. Pylori) Antibody Testing
  • Cardiologists
  • Family Practice Physicians
  • Gastroenterologists
  • Internal medicine physicians
  • Pathologists
  • Pediatricians
  • Serology blood testing (CPT code 86677) will not be covered to test for H. pylori, as it is considered experimental, investigational or unproven.
  • 08/18/2014
Transvaginal Ultrasound(non-obstetrical)
  • Family practice physicians
  • Primary care physicians
  • OB/GYNs
  • Radiologists
  • We will only cover a transvaginal ultrasound (CPT code 76830) when it is used for a woman who has trouble getting pregnant or who has symptoms of, or is at risk for, cancer.
  • We will not cover the use of it for women who are not at risk of cancer and for other unproven uses because it is considered experimental, investigational or unproven.
  • 08/18/2014
Hyaluronate
  • Orthopedic surgeons
  • Rheumatologists
  • Five hyaluronate HCPCS codes will be added to the precertification list:
    • J7323 (EUFLEXXA)
    • J7326 (GEL-ONE)
    • J3490 (MONOVISC)
    • J7324 (ORTHOVISC)
    • J7321 (SUPARTZ / HYALGAN)
    • J7325 (SYNVISC / SYNVISC ONE)
  • 08/18/2014

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The appearance of an item or procedure in this update indicates only that we have recently adopted or revised a policy. It does not imply that we provide coverage for the items or procedures listed. In the event of an inconsistency or conflict between the information provided below and the posted policy, the provisions of the posted policy will prevail.