| Mountain State Medical Policy Bulletin |
| Section: | Miscellaneous |
| Number: | Z-24 |
| Topic: | Miscellaneous Services |
| Effective Date: | November 23, 2009 |
| Issued Date: | November 23, 2009 |
| Date Last Reviewed: | 11/2009 |
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. |
|
| 24357 | 55970 | 55980 | 65770 | 67570 | 82523 |
| 89329 | 89330 | 92512 | 92548 | 92590 | 92591 |
| 92592 | 92593 | 92594 | 92595 | 93740 | 95012 |
| 98966 | 98967 | 98968 | 99174 | 99366 | 99367 |
| 99368 | 99406 | 99407 | 99441 | 99442 | 99443 |
| G0255 | G9016 | P2031 | S0618 | S2107 | S3650 |
| S3652 | S9075 | V5010 |
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. |
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 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 |