Highmark Commercial Medical Policy in West Virginia

Section: Miscellaneous
Number: Z-63
Topic: Procedure Codes Not Applicable to Commercial Products
Effective Date: January 1, 2012
Issued Date: January 2, 2012
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

There are a number of procedure codes that do not apply to commercial products. These codes are typically, but not always, developed by the Centers for Medicare & Medicaid Services (CMS) for the Medicare Program. Often, the terminology for these codes is specific to a Medicare demonstration project or is limited to the Medicare Program in some fashion. (As such, these codes are billable to, and may be covered by, the member's Medicare coverage.)

Unless otherwise specified, these codes are not covered by the Plan under 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 under the member's commercial coverage.

Procedure Codes

G0293G0294G0402G0908G0909G0910
G0911G0912G0913G0914G0915G0916
G0917G0918G0919G0920G0921G0922
G8126G8127G8128G8395G8396G8397
G8398G8399G8400G8401G8404G8405
G8406G8410G8415G8416G8417G8418
G8419G8420G8421G8422G8427G8428
G8430G8431G8432G8433G8440G8441
G8442G8447G8448G8450G8451G8452
G8458G8459G8460G8461G8462G8463
G8464G8465G8468G8469G8470G8471
G8472G8473G8474G8475G8476G8477
G8478G8482G8483G8484G8485G8486
G8487G8489G8490G8491G8492G8493
G8494G8495G8496G8497G8498G8499
G8500G8501G8502G8506G8508G8509
G8510G8511G8524G8525G8526G8530
G8531G8532G8534G8535G8536G8537
G8538G8539G8540G8541G8542G8543
G8544G8545G8546G8547G8548G8549
G8550G8551G8552G8553G8556G8557
G8558G8559G8560G8561G8562G8563
G8564G8565G8566G8567G8568G8569
G8570G8571G8572G8573G8574G8575
G8576G8577G8578G8579G8580G8581
G8582G8583G8584G8585G8586G8587
G8588G8589G8590G8591G8592G8593
G8594G8595G8596G8597G8598G8599
G8600G8601G8602G8603G8604G8605
G8606G8607G8608G8609G8610G8611
G8612G8613G8614G8615G8616G8617
G8618G8619G8620G8621G8622G8623
G8624G8625G8626G8627G8628G8629
G8630G8631G8632G8633G8634G8635
G8636G8637G8638G8639G8640G8641
G8642G8643G8644G8645G8646G8647
G8648G8649G8650G8651G8652G8653
G8654G8655G8656G8657G8658G8659
G8660G8661G8662G8663G8664G8665
G8666G8667G8668G8669G8670G8671
G8672G8673G8674G8675G8676G8677
G8678G8679G8680G8681G8682G8683
G8684G8685G8686G8687G8688G8689
G8690G8691G8692G8693G8694G8695
G8696G8697G8698G8699G8700G8701
G8702G8703G8704G8705G8706G8707
G8708G8709G8710G8711G8712G8713
G8714G8715G8716G8717G8718G8720
G8721G8722G8723G8724G8725G8726
G8727G8728G8730G8731G8732G8733
G8734G8735G8736G8737G8738G8739
G8740G8741G8742G8743G8744G8745
G8746G8747G8748G8749G8750G8751
G8752G8753G8754G8755G8756G8757
G8758G8759G8760G8761G8762G8763
G8764G8765G8767G8768G8769G8770
G8771G8772G8773G8774G8775G8776
G8777G8778G8779G8780G8781G8782
G8783G8784G8785G8786G8787G8788
G8789G8790G8791G8792G8793G8794
G8795G8796G8797G8798G8799G8800
G8801G8802G8803G8805G8806G8807
G8808G8809G8810G8811G8812G8813
G8814G8815G8816G8817G8818G8819
G8820G8821G8822G8823G8824G8825
G8826G8827G8828G8829G8830G8831
G8832G8833G8834G8835G8836G8837
G8838G8839G8840G8841G8842G8843
G8844G8845G8846G8847G8848G8849
G8850G8851G8852G8853G8854G8855
G8856G8857G8858G8859G8860G8861
G8862G8863G8864G8865G8866G8867
G8868G8869G8870G8871G8872G8873
G8874G8875G8876G8877G8878G8879
G8880G8881G8882G8883G8884G8885
G8886G8887G8888G8889G8890G8891
G8892G8893G8894G8895G8896G8897
G8898G8899G8900G8901G8902G8903
G8904G8905G8906G9013G9014G9016
G9017G9018G9019G9020G9033G9034
G9035G9036G9050G9051G9052G9053
G9054G9055G9056G9057G9058G9059
G9060G9061G9062G9063G9064G9065
G9066G9067G9068G9069G9070G9071
G9072G9073G9074G9075G9077G9078
G9079G9080G9083G9084G9085G9086
G9087G9088G9089G9090G9091G9092
G9093G9094G9095G9096G9097G9098
G9099G9100G9101G9102G9103G9104
G9105G9106G9107G9108G9109G9110
G9111G9112G9113G9114G9115G9116
G9117G9123G9124G9125G9126G9128
G9129G9130G9131G9132G9133G9134
G9135G9136G9137G9138G9139G9140
G9156Q4082    

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

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

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 Highmark West Virginia 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.

Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.