December 2020

In This Issue

Coverage Guidelines Revised for Chemodenervation – Botulinum Toxin ...... 2 Criteria Revised for Human Growth Hormone ...... 6 Coverage Guidelines Revised for Electronystagmography (ENG) and Videonystagmography (VNG) Services ...... 7

Contents ...... 13

Policy

Revised Criteria for Wound Care Policy

Highmark Blue Shield has revised criteria for E-31 Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds.

This revised Medical Policy will apply to professional providers and facility claims. The effective date is March 1, 2021.

Place of Service:

Please refer to Medical Policy E-31 Negative Pressure Wound Therapy Pumps/Vacuum Assisted Closure of Chronic Wounds, for additional information.

Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Note: This publication may contain certain administrative requirements, policies, procedures, or other similar requirements of Highmark Inc. (or changes thereto) which are binding upon Highmark Inc. and its contracted providers. Pursuant to their contract, Highmark Inc. and such providers must comply with any requirements included herein unless and until such item(s) are subsequently modified in whole or in part. Medical Policy Update December 2020

Revised Criteria for Non- Powered Negative Pressure Wound Care Policy

Highmark Blue Shield has revised criteria for E-47 Non-Powered Negative Pressure Wound Therapy System. This revised Medical Policy will apply to professional providers and facility claims. The effective date is March 1, 2021.

Place of Service: Outpatient

Please refer to Medical Policy E-47 Non-Powered Negative Pressure Wound Therapy System, for additional information.

Coverage Guidelines Revised for Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

Highmark Blue Shield has revised criteria for Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon to update language regarding celiac disease and removing language in the policy regarding current episode of illness and prior conventional diagnostic testing.

Diagnosis codes have been updated.

This revised Medical Policy will apply to professional providers and/or facility claims. The effective date is March 1, 2021.

Place of Service: Inpatient/Outpatient

Please refer to Medical Policy G-41, Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon, for additional information.

Coverage Guidelines Revised for Chemodenervation – Botulinum Toxin

Highmark Blue Shield has revised coverage criteria for onabotulinumtoxinA (Botox®), AbobotulinumtoxinA (Dysport™), IncobotulinumtoxinA (Xeomin®) and RimabotulinumtoxinB (Myobloc®) to include the following updates:

The following indications will be added to onabotulinumtoxinA (Botox):

• Benign essential blepharospasm or VII nerve disorders are now included in the blepharospasm indication. • Age limit of 16 years or older is now applied to the cervical dystonia (spasmodic torticollis) indication. • Initial authorization period for chronic migraine prevention will be for six (6) months. • Reauthorization will be granted if headache frequency and hours are reduced by at least 50% from baseline. • Urinary incontinence due to detrusor over activity requires an inadequate response to or intolerant of conservative therapy (e.g., moderation of fluid intake, avoidance of 2 Medical Policy Update December 2020

alcohol, caffeine, and medications such as diuretics, control of chronic cough and constipation, smoking cessation, etc.) and medical therapy with an anticholinergic medication. • Upper and lower limb spasticity in individuals 2-17 years of age is an included indication. • Oro-facial-lingual-masticatory tardive dyskinesia due to dopamine blocking agents in adult individuals • Anismus related to pelvic floor dyssynergia in adult individuals who are refractory to biofeedback training, for a maximum of three (3) treatments during a three (3) month period. • Auriculotemporal syndrome in adults to reduce severe symptoms including food- induced facial flushing and sweating or gustatory hyperhidrosis post-parotidectomy (eg. Frey syndrome. • Benign prostatic hyperplasia in adults who no longer respond to medication and refuse surgical treatment with moderate to severe symptoms of urinary obstruction based on the American Urological Association (AUA) index, mean peak urinary flow rate less than 15 mL/sec with voided volume of at least 150 mL, and an enlarged prostate gland. • Cerebral palsy in individuals with upper and lower limb spasticity; or • Detrusor and sphincter dyssynergia in adults due to multiple sclerosis. • Voice failure after tracheoesophageal puncture and prosthesis placements after total laryngectomy in adult individuals (this is due to persistent focal constrictor hypertonicity/spasm). • Disorders of esophagus – dysphagia in adult individuals due to esophageal motility disorder or nonachalasia esophageal motility disorder (ie, diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction). • Dysphagia in adult individuals due to cricopharyngeus muscle spasm or pure upper esophageal sphincter dysfunction. • Estropia, congenital in pediatric individuals age 7 months or younger. • Epicondylitis (e.g. tennis elbow) in adult individuals who did not respond to conventional treatment. • Headache, cervicogenic (whiplash headache) in adult individuals with chronic headache, unrelieved by other therapies, secondary to a cervical whiplash injury which restricts range of motion in the neck. • Hand tremors, severe in adult individuals due to Parkinson disease or essential tremor. • Hemifacial spasms (7th cranial nerve palsy) in adult individuals when failure of oral pharmacological therapies such as carbamazepine, baclofen and benzodiazepine. • Epiphora, functional (e.g. excessive tear production) in adult individuals. • Esophageal achalasia (failure in relaxation of the lower esophageal sphincter with swallowing and by a lack of esophageal peristalsis): in individuals 18 years of age or older who have not responded to dilation therapy or who are considered poor surgical candidates. • Exotropia of third nerve palsy – Acute Injury to oculomotor nerve in adult individuals. • Focal spasticity in pediatric individuals age 2 to 17 years of age with cerebral palsy and concurrent equinus gait (tiptoeing). • Granuloma of the vocal cords in adult individuals refractory to conventional surgical and medical therapies. • Anismus related to pelvic floor dyssynergia in adult individuals who are refractory to biofeedback training, for a maximum of three (3) treatments during a three (3) month period.

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• Auriculotemporal syndrome in adults to reduce severe symptoms including food- induced facial flushing and sweating or gustatory hyperhidrosis post-parotidectomy (eg. Frey syndrome. • Backache in adults with chronic lower back pain. • Benign prostatic hyperplasia in adults who no longer respond to medication and refuse surgical treatment with moderate to severe symptoms of urinary obstruction based on the American Urological Association (AUA) index, mean peak urinary flow rate less than 15 mL/sec with voided volume of at least 150 mL, and an enlarged prostate gland. • Cerebral palsy in individuals with upper and lower limb spasticity; or • Detrusor and sphincter dyssynergia in adults due to multiple sclerosis. • Voice failure after tracheoesophageal puncture and prosthesis placements after total laryngectomy in adult individuals (this is due to persistent focal constrictor hypertonicity/spasm). • Disorders of esophagus – dysphagia in adult individuals due to esophageal motility disorder or nonachalasia esophageal motility disorder (ie, diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction). • Dysphagia in adult individuals due to cricopharyngeus muscle spasm or pure upper esophageal sphincter dysfunction. • Estropia, congenital in pediatric individuals age 7 months or younger. • Epicondylitis (e.g. tennis elbow) in adult individuals who did not respond to conventional treatment. • Hand tremors, severe in adult individuals due to Parkinson disease or essential tremor. • Headache, cervicogenic (e.g. whiplash headache) in adult individuals with chronic headache, unrelieved by other therapies, secondary to a cervical whiplash injury which restricts range of motion in the neck. • Hemifacial spasms (7th cranial nerve palsy) in adult individuals when failure of oral pharmacological therapies such as carbamazepine, baclofen and benzodiazepine. • Epiphora, functional (e.g. excessive tear production) in adult individuals. • Esophageal achalasia (failure in relaxation of the lower esophageal sphincter with swallowing and by a lack of esophageal peristalsis): in individuals 18 years of age or older who have not responded to dilation therapy or who are considered poor surgical candidates. • Exotropia of third nerve palsy – Acute Injury to oculomotor nerve in adult individuals. • Focal spasticity in pediatric individuals age 2 to 17 years of age with cerebral palsy and concurrent equinus gait (tiptoeing). • Granuloma of the vocal cords in adult individuals refractory to conventional surgical and medical therapies. • Temporomandibular joint disorder, chronic in adult individuals. • Thoracic outlet syndrome in adult individuals unresponsive to physical therapy and suboptimally managed with anesthetic and steroid injections. • Tics and associated premonitory symptoms from Gilles de la Tourette’s syndrome in adult individuals. • Whiplash injury to neck in adult individuals with chronic whiplash-associated neck pain following a motor vehicle accident. • Voice tremor, essential (organic) in adult individuals.

The following indications will be removed from onabotulinumtoxinA (Botox):

• Subacute dyskinesia due to drugs.

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• Demyelinating disease of central nervous system, unspecified. • Diplegia of upper limbs. • Focal upper-limb dystonia (e.g., organic writer's cramp) when documentation that abnormal muscle tone is causing persistent pain and/or interfering with functional ability. • Hereditary spastic paraplegia. • Idiopathic torsion dystonia. • Late effects of cerebrovascular disease. • Monoplegia of lower or upper limb. • Multiple sclerosis. • Neuromyelitis optica, • Orofacial dyskinesia. • Other acquired torsion dystonia. • Other demyelinating diseases of central nervous system. • Paraplegia. • Quadriplegia and quadriparesis. • Schilder's disease. • Sequela of spinal cord or traumatic brain injury (e.g. spasticity, intractable headache, etc). • Spastic hemiplegia • Subacute dyskinesia due to drugs • Unspecified monoplegia • Spasmodic dysphonia in the adult individual

The following indication will be added to incobotulinumtoxinA (Xeomin):

• Sialorrhea, chronic due to Parkinson’s disease, atypical parkinsonism, stroke, or traumatic brain injury, with at least a three (3) month history of sialorrhea.

The following requirement will be removed from incobotulinumtoxin A (Xeomin):

• Upper limb spasticity no longer has an age limit.

Add the following indication to rimabotulinumtoxingB (Myobloc):

• Sialorrhea, chronic in individuals 18 years of age or older associated with Parkinson’s disease, ALS, stroke, and other causes with at least a three (3) month history of troublesome sialorrhea refractory to pharmacotherapy (including anticholinergics such as but not limited to scopolamine).

Remove the following indications from rimabotulinumtoxinB (Myobloc): • Ptyalism/sialorrhea (excessive secretion of saliva, drooling) that is associated with advanced Parkinson’s disease; and • Refractory to pharmacotherapy (including anticholinergics such as but not limited to scopolamine).

The Medical Policy will apply to both professional provider and facility claims. The effective date is March 1, 2021.

Please refer to Medical Policy I-11, Chemodenervation – Botulinum Toxin, for additional information.

Place of Service: Outpatient 5 Medical Policy Update December 2020

Criteria Revised for Human Growth Hormone

Highmark Blue Shield has revised criteria for human growth hormone. The following changes were made to the policy:

• Removed the coverage position for idiopathic short stature; • Replaced small for gestational age coverage in children with pathologic growth failure; • Established a policy position for somapacitan (Sogroya®) for use in adults with proven congenital or acquired growth hormone deficiency who meet the following criteria: o Documentation of multiple pituitary growth hormone deficiencies; or o Documentation of central nervous system irradiation; or o The individual has reconfirmation of growth hormone deficiency in adulthood defined as ALL of the following: ▪ Growth velocity of less than 2 cm/year; and ▪ Documentation that epiphyseal fusion has occurred (e.g., bone age greater than 14 for females and greater than 16 for males); and ▪ The individual has not used growth hormone for at least 1 month; and ▪ The individual has a negative response to 2 (two) provocative stimulation tests such as levadopa, clonidine, glucagon, propranolol, arginine, or insulin.

This revised Medical Policy will apply to professional providers and facility claims. The effective date is March 1, 2021.

Place of Service: Outpatient

Please refer to Medical Policy I-12, Human Growth Hormone, for additional information.

Coverage Guidelines Revised for Electronystagmography (ENG) and Videonystagmography (VNG) Services

6 Medical Policy Update December 2020

Highmark Blue Shield has revised coverage guidelines for ENG and VNG services. This will apply to both professional provider and facility claims. The effective date is March 1, 2021.

Place of Service: Outpatient

Please refer to Medical Policy M-7, Electronystagmography (ENG) and Videonystagmography (VNG) Services, for additional information.

Medicare Advantage Policy 7 Medical Policy Update December 2020

Coverage Criteria Revised for Chemodenervation – Botulinum Toxin Highmark’s Medicare Advantage products have revised coverage criteria for onabotulinumtoxinA (Botox®), AbobotulinumtoxinA (Dysport™), IncobotulinumtoxinA (Xeomin®) and RimabotulinumtoxinB (Myobloc®) to include the following:

® OnabotulinumtoxinA (Botox ) may be considered medically necessary when used in the treatment of ANY of the following conditions:

• Blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders in individuals 12 years of age or older characterized by intermittent or sustained closure of the eyelids caused by involuntary contractions of the orbicularis oculi muscle; or • Dystonia, cervical also known as spasmodic torticollis in individuals age 16 years of age or older to reduce the associated severity of abnormal head position and neck pain associated with sustained head tilt or abnormal posturing with limited range of motion in the neck and a history of recurrent involuntary contraction of one or more of the muscles of the neck (e.g. sternocleidomastoid, splenius, trapezius or posterior cervical muscles); or • Chronic migraine prevention in individuals 18 years of age or older for an initial six (6) month trial when ALL of the following criteria are met: o Prescribed by or in consultation with a neurologist or headache specialist; and o A healthcare provider trained in administration of onabotulinumtoxinA (Botox) is administering the drug; and o A diagnosis of chronic migraine headache defined as greater than or equal to 15 days per month for greater than 3 months with features of migraine headache on at least 8 days per month lasting four hours a day or longer [e.g. has been established using the International Classification of Headache Disorders, Third Edition (ICHD-III)]; and o There is a persistent three (3) month history of recurring debilitating headaches as defined above and documented by a headache diary; and o The headaches are not caused by medication rebound (the individual is not taking narcotics or triptans exceeding more than 18 doses per month) or lifestyle issues (e.g., sleep patterns, caffeine use, etc.); and o Adequate trials of prophylactic therapy from at least two (2) different therapy classes (e.g., antiseizure, beta blockers, tricyclic antidepressants) were either not effective or not tolerated. Documentation of trials and failure should include that these medications have been prescribed at adequate doses and for a reasonable length of time (i.e., six weeks each); and • Chronic migraine continued treatment beyond six (6) months (up to four injection treatments in a 12-month period) may be considered medically necessary when ALL the following criteria are met: o Migraine headache frequency reduced by at least 50% from baseline; and o Migraine headache hours reduced at least 50% from baseline; or • Urinary incontinence due to detrusor overactivity due to neurologic condition (e.g., spinal cord injury, multiple sclerosis), that have an inadequate response to or intolerant of conservative therapy (e.g., moderation of fluid intake, avoidance of alcohol, caffeine, and medications such as diuretics, control of chronic cough and constipation, smoking cessation, etc.) and medical therapy with an anticholinergic medication; or

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• Spasticity lower limb in adult individuals to decrease the severity of increased muscle tone in ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor halluces longus, and flexor digitorum longus); or • Spasticity, lower limb in individuals 2 to 17 years of age, excluding spasticity caused by cerebral palsy; or • Overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in adult individuals who have inadequate response to or intolerant of an anticholinergic medication; or • Strabismus associated with dystonia, including benign essential blepharospasm or VII nerve disorders in individuals greater or equal to 12 years of age; or • Spasticity, upper limb in individuals 18 years of age or older, to decrease the severity of increased muscle tone in elbow flexors (biceps), wrist flexors (flexor carpi radialis and flexor carpi ulnaris), finger flexors (flexor digitorum profundus and flexor digitorum sublimis), and thumb flexors (adductor pollicis and flexor pollicis longus); or • Spasticity, upper limb in individual two (2) to 17 years of age.

Injections performed on a more frequent basis may be considered not medically necessary. In addition, more than four (4) injections per region per year may be considered not medically necessary. The use of electrical muscle stimulation or needle electromyography may be considered medically necessary for guidance in conjunction with chemodenervation.

OnabotulinumtoxinA (Botox) and other medically accepted non-FDA approved indications, Class IIB or higher grade recommendation. OnabotulinumtoxinA (Botox) may be considered medically necessary for the following medically accepted non-FDA approved indications when used in the treatment of ANY of the following conditions:

• Anal fissure (chronic) in adult individuals; or • Anismus related to pelvic floor dyssynergia in adult individuals who are refractory to biofeedback training, for a maximum of three (3) treatments during a three (3) month period; or • Auriculotemporal syndrome in adults to reduce severe symptoms including food- induced facial flushing and sweating or gustatory hyperhidrosis post-parotidectomy (eg. Frey syndrome; or • Backache in adults with chronic lower back pain; or • Benign prostatic hyperplasia in adults who no longer respond to medication and refuse surgical treatment with moderate to severe symptoms of urinary obstruction based on the American Urological Association (AUA) index, mean peak urinary flow rate less than 15 mL/sec with voided volume of at least 150 mL, and an enlarged prostate gland; or • Cerebral palsy in individuals with upper and lower limb spasticity; or • Detrusor and sphincter dyssynergia in adults due to multiple sclerosis; or • Voice failure after tracheoesophageal puncture and prosthesis placements after total laryngectomy in adult individuals (this is due to persistent focal constrictor hypertonicity/spasm); or • Disorders of esophagus – dysphagia in adult individuals due to esophageal motility disorder or nonachalasia esophageal motility disorder (ie, diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction); or

9 Medical Policy Update December 2020

• Dysphagia in adult individuals due to cricopharyngeus muscle spasm or pure upper esophageal sphincter dysfunction; or • Esotropia, congenital in pediatric individuals age 7 months or younger; or • Epicondylitis (e.g. tennis elbow) in adult individuals who did not respond to conventional treatment; or • Epiphora, functional (e.g. excessive tear production) in adult individuals; or • Esophageal achalasia (failure in relaxation of the lower esophageal sphincter with swallowing and by a lack of esophageal peristalsis) in individuals 18 years of age or older who have not responded to dilation therapy or who are considered poor surgical candidates; or • Exotropia of third nerve palsy – Acute Injury to oculomotor nerve in adult individuals; or • Focal spasticity in pediatric individuals age 2 to 17 years of age with cerebral palsy and concurrent equinus gait (tiptoeing); or • Granuloma of the vocal cords in adult individuals refractory to conventional surgical and medical therapies; or • Hand tremors, severe in adult individuals due to Parkinson disease or essential tremor; or • Headache, cervicogenic (whiplash headache) in adult individuals with chronic headache, unrelieved by other therapies, secondary to a cervical whiplash injury which restricts range of motion in the neck; or • Headache, Tension-type in adult individuals who have failed at least two (2) prior prophylactic drug therapies; and • History of two (2) or more tension-headache episodes per month for at least the past three (3) months International Headache Society criteria for chronic TTH (pain present for more than 15 days per month and for a duration of at least 6 months); or • Hemifacial spasms (7th cranial nerve palsy) in adult individuals when failure of oral pharmacological therapies such as carbamazepine, baclofen and benzodiazepine; or • Idiopathic trigeminal neuralgia in adult individuals refractory to three (3) to six (6) months of treatment with antiepileptic medications; or • Laryngeal spasm (laryngeal dystonia or spasmodic dysphonia) in adult individuals; or • Larynx closure as an adjunct to surgical treatment in adult individuals; or • Myofascial pain syndrome in adult individuals with fibromyalgia; or • Oro-facial-lingual-masticatory tardive dyskinesia due to dopamine blocking agents in adult individuals; or • Oromandibular dystonia, Isolated in adult individuals refractory to optimal pharmacological therapy, surgery, or both; or • Pharyngoesophageal segment spasm following total laryngectomy in adult individuals as an adjunct to voice therapy program; or • Stuttering in adult individuals; or • Sialorrhea (excessive salivation, drooling) in adult individuals with amyotrophic lateral sclerosis (ALS) or bulbar ALS; or • Sialorrhea (excessive salivation, drooling) in pediatric (2 to 17 years of age) and adult individuals who are neurologically impaired; or • Sialorrhea (excessive salivation, drooling) in pediatric individuals 2 to 17 years of age with cerebral palsy; or • Sialorrhea (drooling or excessive salivation) in adult individuals with functional impairment originating from spasticity or dystonia (conditions of involuntary sustained muscle contraction) resulting from Parkinson disease who have been refractory to pharmacotherapy (including anticholinergics, such as but not limited to scopolamine); or • Temporomandibular joint disorder, chronic in adult individuals; or

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• Thoracic outlet syndrome in adult individuals unresponsive to physical therapy and sub optimally managed with anesthetic and steroid injections; or • Tics and associated premonitory symptoms from Gilles de la Tourette’s syndrome in adult individuals; or • Whiplash injury to neck in adult individuals with chronic whiplash-associated neck pain following a motor vehicle accident; or • Voice tremor, essential (organic) in adult individuals.

Note: Adult individual is defined as individuals 18 years of age or older.

AbobotulinumtoxinA (Dysport™) may be considered medically necessary for the following FDA approved conditions:

• Dystonia, cervical (also known as spasmodic torticollis) in individuals 18 years of age or older; or • Spasticity, upper and lower limb in individuals 18 years of age or older; or • Spasticity, lower limb in pediatric individuals 2 years of age and older

IncobotulinumtoxinA (Xeomin®) may be considered medically necessary for individuals 18 years of age or older for the treatment of:

• Dystonia, cervical (also known as spasmodic torticollis) associated with sustained head tilt or abnormal posturing with limited range of motion in the neck and a history of recurrent involuntary contraction of one or more of the muscles of the neck (e.g. sternocleidomastoid, splenius, trapezius or posterior cervical muscles), to decrease the severity of abnormal head position and neck pain in both botulinum toxin-naive and previously treated individuals; or • Blepharospasm characterized by intermittent or sustained closure of the eyelids caused by involuntary contractions of the orbicularis oculi muscle or facial nerve (VII) disorders including hemifacial spasm in individuals previously treated with onabotulinumtoxinA (Botox); or • Sialorrhea, chronic due to Parkinson’s disease, atypical parkinsonism, stroke, or traumatic brain injury, with at least a three (3) month history of sialorrhea; or • Spasticity, upper limb, to decrease the severity of increased muscle tone in elbow flexors, forearm pronators, wrist flexors, thumb, and finger flexors.

RimabotulinumtoxinB (Myobloc®) may be considered medically necessary for adult individuals for the treatment of:

• Dystonia, cervical (also known as spasmodic torticollis) in individuals 18 years of age or older and a history of recurrent involuntary contraction of one or more of the muscles of the neck (e.g. sternocleidomastoid, splenius, trapezius or posterior cervical muscles); or • Sialorrhea, chronic in individuals 18 years of age or older associated with Parkinson’s disease, ALS, stroke, and other causes with at least a three (3) month history of troublesome sialorrhea refractory to pharmacotherapy (including anticholinergics such as but not limited to scopolamine).

The Medical Policy will apply to both professional provider and facility claims. The effective date is March 1, 2021.

11 Medical Policy Update December 2020

Please refer to Medical Policy I-197, Chemodenervation – Botulinum Toxin, for additional information.

12 Medical Policy Update December 2020

Comments on these new medical policies? We want to know what you think about our new medical policy changes. Send us an email with any questions or comments that you may have on the new medical policies in this edition of Medical Policy Update.

Write to us at [email protected]. Contents Revised Criteria for Wound Care Policy ...... 1 Revised Criteria for Non- Powered Negative Pressure Wound Care Policy ...... 2 Coverage Guidelines Revised for Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon ...... 2 Coverage Guidelines Revised for Chemodenervation – Botulinum Toxin ...... 2 Criteria Revised for Human Growth Hormone ...... 6 Coverage Guidelines Revised for Electronystagmography (ENG) and Videonystagmography (VNG) Services ...... 6 Coverage Criteria Revised for Chemodenervation – Botulinum Toxin ...... 8 Comments on these new medical policies? ...... 13 Contents ...... 13

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About this newsletter

Medical Policy Update is the monthly newsletter for most health care professionals (and office staff) and facilities who participate in our networks and submit claims to Highmark using the 837P HIPAA transaction or the CMS 1500 form, or the 837I HIPAA transaction. Medical Policy Update focuses only on medical policy and claims administration updates, including coding guidelines and procedure code revisions, and is the sole source for this information. For all other news, information and updates, be sure to read Provider News, available on the Provider Resource Center at www.highmarkblueshield.com.

Inquiries about Eligibility, Benefits, Claims Status or Authorizations For inquiries about eligibility, benefits, claim status or authorizations, Highmark Blue Shield encourages providers to use the electronic resources available to them - NaviNet® and the applicable HIPAA transactions – prior to placing a telephone call to the Provider Service Center at 1-866-803-3708.

Acknowledgement The five-digit numeric codes that appear in Medical Policy Update were obtained from the Current Procedural Terminology (CPT), as contained in CPT- 2020, Copyright 2019, by the American Medical Association. Medical Policy Update includes CPT descriptive terms and numeric procedure codes and modifiers that are copyrighted by the American Medical Association. These procedure codes and modifiers are used for reporting medical services and procedures.

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