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| Section: | Miscellaneous |
| Number: | Z-24 |
| Topic: | Miscellaneous Services |
| Effective Date: | January 1, 2010 |
| Issued Date: | January 4, 2010 |
| Date Last Reviewed: | 12/2009 |
Indications and Limitations of Coverage
Charges submitted for the services listed on this medical policy should be denied as noted in the text below. Experimental or InvestigationalExperimental/Investigational services are defined as a treatment, service, procedure, facility, equipment, drug, service or supply (“intervention”) that has been determined not to be medically effective for the condition being treated. Charges submitted for these services listed on this policy should be denied as experimental/investigational. These determinations are based on one or more of the following reasons:
The service is beyond the investigational/experimental stage but is not generally accepted by the medical community as clinically useful in diagnosing or treatment of medical conditions. Therefore, it is considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records. No Professional Service Rendered The following services are to be denied because there is no direct patient care or contact. A participating, preferred, or network provider can bill the member for the denied item or service. Denial of a service based on this reason is not applicable to facility expenses. Facility expenses should be processed according to the member's contractual benefits for the service. The following services are not covered under the member's benefit. This is not an all inclusive list. A participating, preferred, or network provider can bill the member for the denied item or service. ***Under Managed Care programs, payment or denial for this item is based on the individual's contractual benefits. |
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| 11980 | 24357 | 53855 | 55970 | 55980 | 65770 |
| 67570 | 82523 | 83987 | 84431 | 84999 | 86352 |
| 89240 | 89329 | 89330 | 92512 | 92548 | 92590 |
| 92591 | 92592 | 92593 | 92594 | 92595 | 93740 |
| 95012 | 98966 | 98967 | 98968 | 99174 | 99366 |
| 99367 | 99368 | 99406 | 99407 | 99441 | 99442 |
| 99443 | A9270 | G0255 | G9016 | J3490 | P2031 |
| S0618 | S2107 | S3650 | S3652 | S9075 | V5010 |
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This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
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Nitric Oxide Expired Gas Determination Smith AD, Cowan JO, Brassett KP et al. Use of Exhaled Nitric Oxide Measurements to Guide Treatment in Chronic Asthma. The New England Journal of Medicine. 2005; 352 (21): 2163-2173 Deykin A. Targeting Biologic Markers in Asthma - Is Exhaled Nitric Oxide the Bull’s-Eye? The New England Journal of Medicine. 2005; 352 (21): 2233-2235 Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: A randomised controlled trial, The Lancet. 2008;372(9643):1065-1072. Petsky HL, Cates CJ, Li A, et al; Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev 2008 Apr 16; (2):CD006340. Shaw DE, Berry MA, Thomas M, et al. The use of exhaled nitric oxide to guide asthma management: A randomized controlled trial. Am J Respir Crit Care Med. 2007(3);176:231-237. Sivan Y ; Gadish T ; Fireman E ; Soferman R, The use of exhaled nitric oxide in the diagnosis of asthma in school children, J Pediatr. 2009; 155(2):211-6. National Institutes of Health, National Heart, Lung, and Blood Institute, Asthma Education and Prevention Program, Clinical Practice Guidelines. Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma. Aug 28, 2007. Accessed September 9, 2009. Available at URL address: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Endoscopic Radiofrequency Ablation of the Esophagus Fleischer DE, et al. Endoscopic Ablation of Barrett's Esophagus: a Multicenter Study with 2.5-Year Follow-Up. Gastrointestinal Endoscopy. 2008 Nov; 68(5): 867-76 |
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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 circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
