Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: Z-63
Topic: Procedure Codes Not Applicable to Highmark Commercial Products
Effective Date: January 1, 2008
Issued Date: December 31, 2007
Date Last Reviewed: 11/2007

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
G8157G8159G8162G8164G8165G8166
G8167G8170G8171G8172G8182G8183
G8184G8185G8186G8193G8196G8200
G8204G8209G8214G8217G8219G8220
G8221G8223G8226G8231G8234G8238
G8240G8243G8246G8248G8251G8254
G8257G8260G8263G8266G8268G8271
G8274G8276G8279G8282G8285G8289
G8293G8296G8298G8299G8302G8303
G8304G8305G8306G8307G8308G8310
G8314G8318G8322G8326G8330G8334
G8338G8341G8345G8351G8354G8357
G8360G8362G8365G8367G8371G8372
G8373G8374G8375G8376G8377G8378
G8379G8380G8381G8382G8383G8384
G8385G8386G8387G8388G8389G8390
G8391G8395G8396G8397G8398G8399
G8400G8401G8402G8403G8404G8405
G8406G8407G8408G8409G8410G8415
G8416G8417G8418G8419G8420G8421
G8422G8423G8424G8425G8426G8427
G8428G8429G8430G8431G8432G8433
G8434G8435G8436G8437G8438G8439
G8440G8441G8442G8443G8445G8446
G8447G8448G8449G8450G8451G8452
G8453G8454G8455G8456G8457G8458
G8459G8460G8461G8462G8463G8464
G8465G8466G8467G8468G8469G8470
G8471G8472G8473G8474G8475G8476
G8477G8478G8479G8480G8481G8482
G8483G8484G9013G9014G9017G9018
G9019G9020G9033G9034G9035G9036
G9050G9051G9052G9053G9054G9055
G9056G9057G9058G9059G9060G9061
G9062G9063G9064G9065G9066G9067
G9068G9069G9070G9071G9072G9073
G9074G9075G9077G9078G9079G9080
G9083G9084G9085G9086G9087G9088
G9089G9090G9091G9092G9093G9094
G9095G9096G9097G9098G9099G9100
G9101G9102G9103G9104G9105G9106
G9107G9108G9109G9110G9111G9112
G9113G9114G9115G9116G9117G9123
G9124G9125G9126G9128G9129G9130
G9131G9132G9133G9134G9135G9136
G9137G9138G9139G9140Q4082 

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 006 of Z-63]
[Version 005 of Z-63]
[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.