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Section: Miscellaneous
Number: Z-63
Topic: Procedure Codes Not Applicable to Highmark Commercial Products
Effective Date: November 13, 2006
Issued Date: November 13, 2006
Date Last Reviewed: 12/2006

General Policy Guidelines

Indications and Limitations of Coverage

There are a number of procedure codes that do not apply to Mountain State's commercial products.  These codes are typically, but not always, developed by the Centers for Medicare & Medicaid Services (CMS) for the Medicare Part B program.  Often, the terminology for these codes is specific to a Medicare demonstration project or is limited to the Medicare Program in some fashion.

Unless otherwise specified, these codes are not covered by Mountain State under its commercial products and should not be billed to our members.  A participating, preferred, or network provider cannot bill the member for these non-covered services.

Procedure Codes

G0293G0294G0344G8006G8007G8008
G8009G8010G8011G8012G8013G8014
G8015G8016G8017G8018G8019G8020
G8021G8022G8023G8024G8025G8026
G8027G8028G8029G8030G8031G8032
G8033G8034G8035G8036G8037G8038
G8039G8040G8041G8051G8052G8053
G8054G8055G8056G8057G8058G8059
G8060G8061G8062G8075G8076G8077
G8078G8079G8080G8081G8082G8085
G8093G8094G8099G8100G8103G8104
G8106G8107G8108G8109G8110G8111
G8112G8113G8114G8115G8116G8117
G8126G8127G8128G8129G8130G8131
G8152G8153G8154G8155G8156G8157
G8158G8159G8160G8161G8162G8163
G8164G8165G8166G8167G8170G8171
G8172G8182G8183G8184G8185G8186
G9017G9018G9019G9020G9033G9034
G9035G9036G9050G9051G9052G9053
G9054G9055G9056G9057G9058G9059
G9060G9061G9062G9063G9064G9065
G9066G9067G9068G9069G9070G9071
G9072G9073G9074G9075G9076G9077
G9078G9079G9080G9081G9082G9083
G9084G9085G9086G9087G9088G9089
G9090G9091G9092G9093G9094G9095
G9096G9097G9098G9099G9100G9101
G9102G9103G9104G9105G9106G9107
G9108G9109G9110G9111G9112G9113
G9114G9115G9116G9117G9118G9119
G9120G9121G9122G9123G9124G9125
G9126G9127G9128G9129G9130 

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

08/2006, Procedure Codes not applicable to Highmark Commercial Products

References

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Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.


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