Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: Z-63
Topic: Procedure Codes Not Applicable to Highmark Commercial Products
Effective Date: July 1, 2007
Issued Date: September 10, 2007
Date Last Reviewed: 06/2007

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

G0293G0294G0344G0377G8006G8007
G8008G8009G8010G8011G8012G8013
G8014G8015G8016G8017G8018G8019
G8020G8021G8022G8023G8024G8025
G8026G8027G8028G8029G8030G8031
G8032G8033G8034G8035G8036G8037
G8038G8039G8040G8041G8051G8052
G8053G8054G8055G8056G8057G8058
G8059G8060G8061G8062G8075G8076
G8077G8078G8079G8080G8081G8082
G8085G8093G8094G8099G8100G8103
G8104G8106G8107G8108G8109G8110
G8111G8112G8113G8114G8115G8116
G8117G8126G8127G8128G8129G8130
G8131G8152G8153G8154G8155G8156
G8157G8158G8159G8160G8161G8162
G8163G8164G8165G8166G8167G8170
G8171G8172G8182G8183G8184G8185
G8186G8191G8192G8193G8194G8195
G8196G8197G8198G8199G8200G8201
G8202G8203G8204G8205G8206G8207
G8208G8209G8210G8211G8212G8213
G8214G8215G8216G8217G8218G8219
G8220G8221G8222G8223G8224G8225
G8226G8227G8228G8229G8230G8231
G8232G8234G8235G8236G8237G8238
G8239G8240G8241G8242G8243G8245
G8246G8247G8248G8249G8250G8251
G8252G8253G8254G8255G8256G8257
G8258G8259G8260G8261G8262G8263
G8264G8265G8266G8267G8268G8269
G8270G8271G8272G8273G8274G8275
G8276G8277G8278G8279G8280G8281
G8282G8283G8284G8285G8286G8287
G8288G8289G8290G8291G8292G8293
G8294G8295G8296G8297G8298G8299
G8301G8302G8303G8304G8305G8306
G8307G8308G8309G8310G8311G8312
G8313G8314G8315G8316G8317G8318
G8319G8320G8321G8322G8323G8324
G8325G8326G8327G8328G8329G8330
G8331G8332G8333G8334G8335G8336
G8337G8338G8339G8340G8341G8342
G8343G8344G8345G8346G8347G8348
G8349G8350G8351G8352G8353G8354
G8355G8356G8357G8358G8359G8360
G8361G8362G8363G8364G8365G8366
G8367G8368G9013G9014G9017G9018
G9019G9020G9033G9034G9035G9036
G9050G9051G9052G9053G9054G9055
G9056G9057G9058G9059G9060G9061
G9062G9063G9064G9065G9066G9067
G9068G9069G9070G9071G9072G9073
G9074G9075G9077G9078G9079G9080
G9083G9084G9085G9086G9087G9088
G9089G9090G9091G9092G9093G9094
G9095G9096G9097G9098G9099G9100
G9101G9102G9103G9104G9105G9106
G9107G9108G9109G9110G9111G9112
G9113G9114G9115G9116G9117G9123
G9124G9125G9126G9128G9129G9130
G9131G9132G9133G9134G9135G9136
G9137G9138G9139Q4082  

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

References

View Previous Versions

[Version 004 of Z-63]
[Version 003 of Z-63]
[Version 002 of Z-63]
[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.