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Section: Miscellaneous
Number: Z-63
Topic: Procedure Codes Not Applicable to Highmark Commercial Products
Effective Date: January 1, 2007
Issued Date: January 1, 2007
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

G0293G0294G0344G0380G0381G0382
G0383G0384G8006G8007G8008G8009
G8010G8011G8012G8013G8014G8015
G8016G8017G8018G8019G8020G8021
G8022G8023G8024G8025G8026G8027
G8028G8029G8030G8031G8032G8033
G8034G8035G8036G8037G8038G8039
G8040G8041G8051G8052G8053G8054
G8055G8056G8057G8058G8059G8060
G8061G8062G8075G8076G8077G8078
G8079G8080G8081G8082G8085G8093
G8094G8099G8100G8103G8104G8106
G8107G8108G8109G8110G8111G8112
G8113G8114G8115G8116G8117G8126
G8127G8128G8129G8130G8131G8152
G8153G8154G8155G8156G8157G8158
G8159G8160G8161G8162G8163G8164
G8165G8166G8167G8170G8171G8172
G8182G8183G8184G8185G8186G8191
G8192G8193G8194G8195G8196G8197
G8198G8199G8200G8201G8202G8203
G8204G8205G8206G8207G8208G8209
G8210G8211G8212G8213G8214G8215
G8216G8217G8218G8219G8220G8221
G8222G8223G8224G8225G8226G8227
G8228G8229G8230G8231G8232G8234
G8235G8236G8237G8238G8239G8240
G8241G8242G8243G8245G8246G8247
G8248G8249G8250G8251G8252G8253
G8254G8255G8256G8257G8258G8259
G8260G8261G8262G8263G8264G8265
G8266G8267G8268G8269G8270G8271
G8272G8273G8274G8275G8276G8277
G8278G8279G8280G8281G8282G8283
G8284G8285G8286G8287G8288G8289
G8290G8291G8292G8293G8294G8295
G8296G8297G8298G8299G8300G8301
G8302G8303G8304G8305G8306G8307
G8308G8309G8310G8311G8312G8313
G8314G8315G8316G8317G8318G8319
G8320G8321G8322G8323G8324G8325
G8326G8327G8328G8329G8330G8331
G8332G8333G8334G8335G8336G8337
G8338G8339G8340G8341G8342G8343
G8344G8345G8346G8347G9013G9014
G9017G9018G9019G9020G9033G9034
G9035G9036G9050G9051G9052G9053
G9054G9055G9056G9057G9058G9059
G9060G9061G9062G9063G9064G9065
G9066G9067G9068G9069G9070G9071
G9072G9073G9074G9075G9077G9078
G9079G9080G9083G9084G9085G9086
G9087G9088G9089G9090G9091G9092
G9093G9094G9095G9096G9097G9098
G9099G9100G9101G9102G9103G9104
G9105G9106G9107G9108G9109G9110
G9111G9112G9113G9114G9115G9116
G9117G9123G9124G9125G9126G9128
G9129G9130G9131G9132G9133G9134
G9135G9136G9137G9138G9139Q4082

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

10/2006, More procedure codes identified as not applicable to Blue Shield Commercial Products

References

View Previous Versions

[Version 001 of Z-63]

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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