PROVIDERNews Catch One of These Radiology Management Program Webinars
Providers who weren’t able to attend the Radiology Management Program overviews held at our recent Mountain State Provider Workshops will have more opportunities to learn this important information.
Twelve webinar sessions have been scheduled in November and December to allow providers to hear tips for how to prepare for the program. Representatives from National Imaging Associates, Inc. (NIA) will conduct two 90-minute sessions on each of the following dates:
® Nov. 16, 2010, 8 a.m. and noon ® Nov. 17, 2010, 8 a.m. and noon ® Dec. 7, 2010, 8 a.m. and noon ® Dec. 8, 2010, 8 a.m. and noon ® Dec. 14, 2010, 8 a.m. and noon ® Dec. 15, 2010, 8 a.m. and noon
Registration is required. Please click here to access the registration form.
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Inside This Edition: Radiology Management Program 2 Prescription Drug Benefit Management Moving 10 Paperless EOB and EFT 2 Watch Your Mail for News about FreedomBlueSM NaviNet® Verification Process 3 PPO and BlueRxSM PDP Changes 11 Mountain State Automates Electronic Changes for Service Benefit Plan FEP Members 11 Professional Claim Adjustments Requests 4 National Consumer Cost Tool Initiative 13 Mountain State to Revise COB Process 6 Mountain State to Update Its List of Procedures Coverage for Certain OTC Medications 6 Requiring Authorization 13 October 2010 Medicare Advantage News 7 Contracting/Reimbursement Update 14 Need help getting ready for ICD-10? 8 Please Note Important Holiday Observances 16 HIPAA News 9 Welcome to Our Newest Groups 16 Procedure Codes Relevant to Dental Services 10 Medical Policy Updates 17 PROVIDERNews
Catch One of These Radiology Management Program Webinars (Continued from page 1)
You will need a computer with Internet access to view the educational materials presented during the webinar.
Please send your completed registration form to Kristy Over by fax at 1-888-656-6350 or via e-mail at [email protected] at least one (1) week before the scheduled webinar date. After you RSVP, you will receive a confirmation e-mail from NIA for the webinar session you selected.
Radiology Management Program: First Date to Begin Contacting NIA for Prior Authorization is Dec. 20, 2010 The Radiology Management Program begins Jan. 1, 2011. For dates of service on or after Jan. 1, 2011, providers can begin contacting NIA on Dec. 20, 2010. For additional details about the Radiology Management Program, please see page 4 of the August 2010 issue of Provider News.
Moving to Paperless Explanation of Benefits (EOB) Statements and Electronic Funds Transfer (EFT)
As announced previously, beginning Oct. 1, 2010, and continuing throughout 2011, Mountain State will require our network practitioners to enroll in NaviNet® and receive paperless EOB statements and EFT. These electronic transactions provide enhanced protection of both member and practitioner data and provide you with faster reimbursement.
For more information, please see page 2 of the August 2010 issue of Provider News.
2 October 2010 NaviNet® Streamlines Verification Process for Hospital Clerk
Hold the phone!
The expression could certainly be used to describe how Laurel Shourds would spend much of her past days as an insurance verification clerk at St. Joseph’s Hospital in Parkersburg. Over the years, Ms. Shourds had come to accept being on hold for extended periods when placing telephone calls to insurers to verify patient benefits and to obtain authorizations for procedures.
So when she heard that an Internet-based ® tool called NaviNet could help her get more Laurel Shourds, left, with Brenda Amos, Patient Access Supervisor, accomplished in less time, she was skeptical. at St. Joseph’s Hospital in Parkersburg. Ms. Shourds is now able to provide insurance verification information to the hospital a full month “When you do a job one way for a number of years, ahead of scheduled procedures, thanks to NaviNet. you’re resistant to change,” Ms. Shourds explains. “The thought of doing things electronically was a bit Ms. Shourds finds comfort in NaviNet’s reliability intimidating. I wasn’t confident that I’d be able to get and speed. “I use it the most for Mountain State the information I needed.” patients,” she notes. “I find there’s very little downtime and when there is downtime, it’s taken But in a very short time, she was happy to discover care of very quickly. I like being able to go into the what she’d been told about NaviNet was true. Within system and, within a few minutes, find out exactly a week, she was comfortable with the system and what I’m looking for. was saying goodbye to the telephone for verifying the benefits of the hospital’s Mountain State “The first thing I do in the morning is sign on to patients. NaviNet because I’m in and out of it all day.”
“Once I realized how much information I could get, Now that she’s experienced the advantages of how quickly I could get it and how dependable NaviNet, she can’t imagine going back to the NaviNet is, I was hooked,” she recalls. “I’m definitely telephone. a fan.” “The hold times were frustrating,” she says, Learning NaviNet was easy, Ms. Shourds adds, and noting that holds could last anywhere from three within a week she was comfortable using it. “Once I to 15 minutes. “The sheer volume of how many understood the menus, where I needed to go to get verifications and authorizations I have to do is what I needed, it didn’t take that long. It’s very user significant.” Because Ms. Shourds could only do friendly. Once you get into a plan, the information is verifications and authorizations for three patients at easy to look at, read and understand,” Ms. Shourds a time by telephone, it really slowed her down. says. For each patient, Ms. Shourds must determine his The layout is clean and features terms that are easy or her deductible, coinsurance and out-of-pocket to comprehend, she adds. “The facts and figures are maximums and record how much he or she has met right in front of you, where you need them.” or still owes. She enters that data into the hospital’s system, which the preregistration staff uses to inform patients of their financial responsibility prior to their procedure. (Continued on page 4
3 PROVIDERNews NaviNet® Streamlines Verification Process for Hospital Clerk (Continued from page 3)
“With NaviNet, I can do as many (verifications) as The process isn’t always as smooth for other health I need to whenever I need to,” she says. NaviNet plans that do not have a system like NaviNet, she says. makes my job so much more pleasant. It’s enabled me to get out farther on our schedules for high- “We’ve had an experience where a patient was dollar surgeries, CAT scans, MRI and nuclear already in the hospital waiting for a procedure and medicine procedures.” we could not proceed until I could get through to someone from the health plan to verify the patient’s Ms. Shourds prefers to have the information eligibility and benefits,” Ms. Shourds recalls. available to the preregistration staff at least three weeks before scheduled procedures. Thanks to After experiencing its many advantages, NaviNet, she’s been able to provide that data one Ms. Shourds would recommend NaviNet to her month ahead of procedures. colleagues. “By all means, use it,” she says. “It’s quick, it’s reliable, and it’s user friendly.
“My life would certainly be a lot more hectic without it.”
Mountain State Automates Electronic Professional Claim Adjustments Requests
You, along with Mountain State Blue Cross Blue original claim number Shield, benefit from efforts to streamline claim assigned by Blue Cross adjustments. The HIPAA 837P, which allows you to Blue Shield is required on submit a claim adjustment request, has now been this type of submission. automated. Frequency Type 8 is a Void/ Cancellation of a prior claim. Frequency Type 8 Please analyze your adjustments to determine is used to completely void a claim that was reported whether there are opportunities to initiate electronic in error. The original claim number assigned by claim adjustment requests. It is important that you Blue Cross Blue Shield is required on this type of also find out if these additional claim types are submission. supported by your claim submission vendor. In the HIPAA 837P Claim Transaction, the There are three valid Frequency Type Claims that Frequency Type Code is reported in the 2300 Loop, can be initiated: CLM05-3 element. The original claim number is reported in Loop 2300, ORIGINAL REFERENCE Frequency Type 1 is an original claim. All new NUMBER (ICN/DCN) REF segment. claims are submitted with this value. Adjusted claims can also be submitted using the Frequency Type 7 is a replacement of a prior NaviNet® Claim Submission/1500 claim submission claim. Frequency Type 7 is used to correct data transaction, then selecting the appropriate reported incorrectly on the original claim. The frequency type code, and providing the original claim number on the “Header” page.
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4 October 2010
When to bill for a replacement Mountain State action Examples of corrected claims that claim (Frequency Type 7) can be submitted When to use Use Frequency Type 7 when Mountain The initial claim is identified based on the When a change is made to a service, State has processed a specific claim for original claim number reported. such as: payment and you, the provider, identified ® incorrect procedure or diagnosis code an error on the original claim that needs The replacement claim data is used to to be corrected. Information present review, reprocess and adjust the original ® incorrect place of service on this claim represents a complete or claim as appropriate. The result of this ® incorrect total charge partial replacement of the previously action could be an additional payment, ® submitted claim. no change in payment or recovery of an incorrect units overpayment.
The Frequency Type 7 or replacement claim will be reflected as a denied claim on the EOB and/or electronic remittance: Denials on the EOB will report Blue Cross Blue Shield proprietary code ― E0775: The adjustment request received from the provider has been processed. The original claim has been adjusted based on the information received.
On the 835, Claim Adjustment Group and Reason Code ― OA125: Submission/ billing error will be used to deny the claim.
When to bill for a voided claim Mountain State action Examples of corrected claims that (Frequency Type 8) can be submitted When to use
Frequency Type 8 is used when you The initial claim is identified based on the When a change is made to a service, want to entirely eliminate a previously original claim number reported. such as: submitted claim. This code will cause the ® change of provider number claim to be completely cancelled from The Frequency Type 8 claim data is used Mountain State’s system. Any service on to void the original claim from Mountain ® change to member identification this claim that should be processed will State’s system. Normal offset processes need to be submitted under a new claim are followed. for payment. The new, corrected claim may be submitted the same time the The Frequency Type 8 claim will be voided claim is submitted. If the claim reflected as a denied claim on the was submitted in error, no additional electronic remittance and/or EOB: action by the provider is required. Denials on the EOB will report Mountain State proprietary code ― E0775: The adjustment request received from the provider has been processed. The original claim has been adjusted based on the information received.
On the 835, Claim Adjustment Group and Reason Code ― OA125: Submission/ billing error will be used to deny the claim.
5 PROVIDERNews Mountain State to Revise COB Process, Effective Jan. 1, 2011 Mountain State will revise our current Coordination Effective with dates of service Jan. 1, 2011, and of Benefits (COB) process effective Jan. 1, 2011. beyond, when Mountain State is secondary to a This new process will bring Mountain State into third party payer other than Medicare, its liability will compliance with the West Virginia Department not exceed the lesser of member liability under the of Insurance’s National Association of Insurance primary payer’s plan or Mountain State’s payment Commissioners’ (NAIC) model for processing COB allowance. In either case, secondary payment may claims. be reduced or eliminated if the plan participant has not complied with the primary plan’s managed care requirements or goes to a health care provider not in the primary payer’s network. Health Care Reform Legislation Allowing Coverage for Certain Over-the-Counter (OTC) Medications Considered to be Preventive
Prescriptions required for reimbursement in five categories, when applicable to the patient
One of the provisions of the Patient Protection and e Aspirin – Men age 45-79, women age 55-79 Affordable Care Act (PPACA) is preventive services. Within that provision, reimbursement may be r Folic Acid – Applies to women who are available to the patient for certain over-the-counter planning and capable of pregnancy (OTC) medications considered to be preventive in nature. The reimbursement opportunity could start t Iron – Routine iron supplementation for to be applicable to certain patients on or after asymptomatic children age 6-12 months who Oct. 1, 2010, depending on the type of coverage are at increased risk of iron deficiency anemia they have, and when their policy renews. u Fluoride – For preschool children (age > 6 months) with low fluoride exposure (water Therefore, it’s important for providers to know source deficient of fluoride), primary care that you may be asked by your patients to write a physicians should prescribe oral fluoride prescription for these targeted OTC medications supplements as defined at right. The reason is that members will require a prescription from their provider, and i Smoking Cessation – Combination therapy will need to follow a certain procedure to submit for with counseling and medication is more reimbursement of their out-of-pocket expense. effective at increasing cessation rates. For non- pregnant adults (> 18 years), therapy includes nicotine replacement therapy (gum, lozenge, patch, inhaler and nasal spray) and sustained release bupropion and varenicline
6 October 2010
Medicare Advantage News: A Focus on Reducing Fall Risk
The Centers for Medicare & Medicaid Services Most of these measures are based on a member (CMS) rates health plans on a one-to-five star scale. survey, and it is understood that members may The ratings can be found at www.medicare.gov and not recall that their physician discussed fall risk, demonstrate that the Highmark Health Insurance were assessed for urinary continence, advised Company (HHIC) Medicare Advantage health plan, about engaging in physical activity or discussed FreedomBlueSM PPO, provides high-quality services osteoporosis. But often these discussions may not to its members. This is largely attributable to the occur because of other priorities during the office efforts of the vast network of physicians who provide visit. Therefore, HHIC has developed a tool that care to these Highmark members. has been mailed to members to complete and take to the physician office to facilitate the assessment However, based on review of performance of fall risk, one of these key assessment areas. measures, it is noted that opportunities for The tool, which is attached to this issue of Provider improvement exist for certain measures to impact News, is intended to support physicians in activating the quality of care for members, in addition to an appropriate plan of care. HHIC hopes the improving the star ratings. These measures are: physicians caring for its senior members will find this tool to be helpful. ® Fall Risk Management ® Improving Bladder Control If you would like to have tablets with this assessment form available in your office for ® Physical Activity distribution to patients, please notify your Mountain State Medical Management consultant or Provider ® Spirometry Testing Relations representative. Posters to remind members to talk to their doctor about fall risk, ® Osteoporosis Testing and Management bladder control and physical activity can also be obtained.
7 PROVIDERNews Need help getting ready for ICD-10?
What are the steps we need to take to prepare or superbills, practice management system, our office for ICD-10? How do we get started? electronic health record system, contracts, and Are training and educational resources available? public health and quality reporting protocols. If you have these and other questions, you are not Each one of these sources should be analyzed alone. As you and your office staff become more to determine the steps and effort needed to aware of how the transition to ICD-10 will affect your transition to ICD-10. business, it can seem overwhelming. Another helpful hint: Identify the ICD-9 codes that The good news is there are a number of resources you use most often. There are significantly more that provide this type of information and can ICD-10 codes than ICD-9 codes. If you identify help your office get started preparing for ICD-10. the codes you use most often, it may be easier to Internet sites for organizations such as the Centers determine, prepare, educate, and transition your for Medicare & Medicaid Services (CMS), the operations. Workgroup for Electronic Data Interchange (WEDI) and the American Academy of Professional Coders There are training opportunities and materials (AAPC) offer information on transition planning, available through professional associations, training and ICD-10 itself. online courses, webinars and onsite training. Some courses are tailored specifically to On page 10 of the August 2010 issue of Provider physicians, practice administrators or coders. News, Mountain State outlined a few steps to help For example, a practice administrator may you get started. One step involves assessing where require training now to better plan and manage and how your practice uses ICD-9 today. This could the transition to ICD-10. Training for coders include clinical documentation, encounter forms may be deferred until closer to the Oct. 1, 2013, compliance date.
The AAPC has constructed a set of benchmarks that call for current completion of an impact assessment, a determination of a transition budget and development of an education plan. While this is just one source, the message is clear: it is not too early to begin preparations for the transition to ICD-10.
8 October 2010 Mountain State now ready to receive HIPAA version 005010 electronic claim related transactions
Mountain State Blue Cross Blue Shield is now When I begin to submit claims in version able to receive version 005010 claim transactions 005010, will I also receive my electronic and send version 005010 remittance and remittance advice (ERA) in version 005010? acknowledgment transactions in production. No. There is a separate authorization and This includes these transactions: testing process for ERA, although testing is not ® 837 I, P—Health Care Claim Institutional (I) required. When ready, the Mountain State trading and Professional (P) partner that handles electronic transactions with Mountain State for your office must submit a ® 835—Health Care Claim Payment/Advice separate request to receive ERAs, that is, 835 ® 999—Implementation Acknowledgment for transactions in version 005010. Health Care Insurance ® 277CA—Health Care Claim Acknowledgment Version 005010 Companion Guide Mountain State’s Provider EDI Companion Here are some common questions and answers to Guide for version 005010 transactions is now help you learn about exchanging version 005010 available through the Highmark EDI Trading claim transactions with Mountain State. Partner Business Center. The Companion Guide has been added to the Resources section What do I need to do to submit electronic claims to help Mountain State’s trading partners with to Mountain State in version 005010? submitting and receiving professional claim, claim Your clearinghouse, billing service or software acknowledgment, and claim payment electronic vendor must be approved as a version 005010 transactions to Mountain State. The Companion trading partner by Mountain State. Then you Guide supplements the HIPAA version 005010 may begin to submit version 005010 claims to national implementation guides and errata with Mountain State. clarifications and payer-specific usage and content requirements. Please contact your clearinghouse, billing service or software vendor to find out when they’ll be Version 005010 compliance is critical certified for version 005010 transactions. The Department of Health and Human Services’ (HHS) regulations require that as of Jan. 1, 2012, Will I need to code and submit version 005010 only version 005010 transactions will be accepted claims any differently than I do today? and sent between HIPAA-covered entities, which Mountain State highlighted possible changes to include providers, clearinghouses and payers. a provider’s office operations to support version Therefore, Mountain State will reject any claims 005010 on page 4 of the June 2010 issue of submitted using a version 004010A1 transaction Provider News in an article titled “Make preparations format after the compliance date. for new requirements for claims submissions due to HIPAA 5010 related system changes.” The impact If you have general questions about the changes of those changes will be determined by the systems being made by Mountain State to become version used in your office. 005010 compliant, please contact your Provider Relations representative. If you have questions Please contact the clearinghouse or billing service specific to the version 005010 authorization that is your interface to Mountain State or the process or electronic claim transactions, please software vendor who is responsible for your office call Mountain State’s EDI Operations department system for more information. at 1-888-222-5950. Watch Provider News for more information and updates about the transition to HIPAA version 005010 transactions.
9 PROVIDERNews List of Procedure Codes Relevant to Mountain State Medical Policy D-6 (Dental Services) As announced on page 26 of the June 2010 issue of Provider News, Mountain State Medical Policy D-6 (Dental Services) states that dental extractions such as removal of wisdom teeth may be considered medically necessary when performed in places of service other than office, effective with dates of service on or after Oct, 11, 2010. Below are the procedure codes relevant to Medical Policy D-6: ® D7220 – Removal of Impacted Tooth – Soft tissue ® D7230 – Removal of Impacted Tooth – Partially bony ® D7240 – Removal of Impacted Tooth – Completely bony ® D7241 – Removal of Impacted Tooth – Completely bony, with unusual surgical complications
For more information please refer to the article on page 26 of the June 2010 issue of Provider News.
Mountain State Prescription Drug Benefit Management Moving to Highmark, Effective Jan. 1, 2011
As Mountain State physicians are aware, Medco currently manages the prescription drug benefit, including prior authorization requests for certain prescription medications, for New Blue® indemnity, SuperBlue® Plus preferred provider plan, SuperBlue Select point of service plan and Highmark Health Insurance Company (HHIC) FreedomBlueSM PPO Medicare Advantage plan. Effective with dates of service on or after Jan. 1, 2011, Highmark will manage the prescription drug benefit for those products. However, Medco will continue to be the claims processor for prescription drug claims for dates of service on or after Jan. 1, 2011.
For additional information, please refer to the Special Bulletin dated September 23, 2010 and titled “Mountain State Prescription Drug Benefit Management Moving to Highmark, Effective Jan. 1, 2011.”
10 October 2010
Watch Your Mail for News about Important FreedomBlueSM PPO and BlueRxSM PDP Changes for 2011 Highmark Health Insurance Company (HHIC) FreedomBlue PPO providers will soon receive Special Bulletins regarding important changes for FreedomBlue PPO and BlueRx PDP benefits for 2011 as well as details on coverage for post- cataract services. Please watch your mail, the News & Bulletins section of www.msbcbs.com and the Plan Central page of NaviNet® for these important announcements.
2011 Benefit Changes for Service Benefit Plan FEP Members
Several benefit changes have been made to the providers when the services are performed in the Federal Employees Health Benefits Plan (FEP) for emergency room. It will also be 15 percent of the 2011. These changes are outlined below. Plan allowance for medical emergency treatment provided by Member and Non-member facilities Changes to Standard Option when services are performed in the emergency ® The calendar year deductible is $350 per person room. and $700 per family. ® The copayment for certain outpatient mental ® The coinsurance amount for preventive care health and substance abuse services performed services for children performed by Participating by both Preferred primary care and specialist and Non-Participating providers is 35 percent providers is $20 per visit. There will be no of the Plan allowance after the calendar year member cost share for inpatient mental health deductible is satisfied. and substance abuse services they receive from Preferred professional providers. ® There is a $250 per admission for inpatient care, including inpatient hospice care, at Preferred Changes to Basic Option facilities, and $350 per admission, plus 35 percent of the Plan allowance, for inpatient care, ® The copayment for preferred brand-name drugs including inpatient hospice care, at Member purchased at a Preferred Retail Pharmacy is facilities. $40 per prescription for up to a 34-day supply. In addition, the minimum amount for non-preferred ® Benefits for outpatient surgery and related brand-name drugs is $50 for each 34-day supply, services performed and billed for by a hospital or $150 for a 90-day supply. or freestanding ambulatory facility is subject to the calendar year deductible. Members ® The copayment for EEGs, ultrasounds, and will pay 15 percent of the Plan allowance for x-rays is $25. medical emergency treatment provided by Participating and Non-participating professional (Continued on next page)
11 PROVIDERNews 2011 Benefit Changes for Service Benefit Plan FEP Members (Continued from page 11)
® The copayment for CT scans, MRIs, PET scans, ® There are benefits to cover up to four mental diagnostic bone density tests, nuclear medicine, health visits per year in full for treatment of diagnostic angiography, and diagnostic genetic maternity-related depression at a Preferred testing is $75. provider. Prior Approval is no longer required ® The copayment for surgery is $150 per before receiving outpatient professional or performing surgeon per day. outpatient facility care for mental health and substance abuse treatment. Previously, prior ® The copayment for emergency room care related approval was required. to an accidental injury or medical emergency is $125 per visit. The copayment for care provided ® Benefits are now provided in full for smoking at Preferred urgent care centers related to cessation treatment when using a Preferred accidental injuries and medical emergencies is provider. $50 per visit. ® Hearing/Speech Aid benefits are provided in ® The copayment for professional charges for full up to $1,000 per hearing aid per ear for intensive outpatient treatment in a provider’s hearing aids for children, hearing aids for adults, office or other professional setting is $25 per and bone-anchored hearing aids for adults and visit. children, when provided by any qualified hearing aid provider. Benefits are provided in full up to ® The copayment for certain outpatient mental $1,000 per calendar year for speech-generating health and substance abuse services performed devices obtained from any qualified provider. by both Preferred primary care and specialist providers is $25 per visit. ® Benefits are provided for osteopathic and chiropractic manipulative treatment, including ® The copayment for outpatient mental health and extraspinal manipulations performed by substance abuse services provided and billed by chiropractors, limited to a combined total of 12 a Preferred facility is $25 per day per facility. manipulation visits per year under Standard ® Benefits will be provided in full for drugs and Option and 20 manipulation visits per year under supplies related to outpatient mental health Basic Option. and substance abuse care from Preferred ® Clarifications/Recognitions: Specific pre-surgical professional and facility providers. criteria must be met before receiving surgery for morbid obesity. We will provide benefits for Changes to both Standard and Basic Options additional types of organ/tissue transplants and ® We will provide preventive care benefits in full to have enhanced our organ/tissue transplant prior cover preventive services for adults and children approval procedures for members and providers. recommended under the Affordable Care Act We will provide benefits for donor screening when using a Preferred provider. We will provide tests and donor search expenses related to preventive care benefits for adult screenings for blood or marrow stem cell transplants when gonorrhea infection, Human Immunodeficiency performed on three potential non-full siblings. Virus (HIV) infection, and syphilis infection. Prior approval will no longer be required for Preventive benefits will be covered in full for outpatient intensity-modulated radiation therapy nutritional counseling visits for adults and (IMRT) to treat head, neck, breast, or prostate children when using Preferred providers. cancer. Prior approval continues to be required for IMRT to treat all other types of cancer. We reorganized organ and tissue transplant benefit information to clarify coverage. We reorganized Mental health and substance abuse benefits to clarify coverage.
12 October 2010 Mountain State’s Required Participation in the Blue Cross and Blue Shield Association’s National Consumer Cost Tool Initiative
Hospitals and ambulatory surgery centers are reminded that through the National Consumer Cost Tool Initiative, members of all Blue Cross and/or Blue Shield Plans will be able to view and compare minimum and maximum estimated bundled cost information for certain inpatient and outpatient procedures performed by Mountain State Blue Cross Blue Shield (MSBCBS) contracted facilities, beginning in late fall 2010.
For complete details, please refer to the Facility Bulletin dated August 26, 2010, and titled “Mountain State Blue Cross Blue Shield’s Required Participation in the Blue Cross and Blue Shield Association’s National Consumer Cost Tool Initiative.”
Mountain State to Update Its List of Procedures Requiring Authorization
Effective Feb. 1, 2011, Mountain State Blue Cross Blue Shield (MSBCBS) will revise its list of procedures requiring authorization to add 92 codes. Click here to access a chart outlining the procedure codes that will be added to the authorization list, effective Feb. 1, 2011. (Please note, the codes will not have authorization requirements and will not appear on the all-inclusive authorization list on the MSBCBS Provider website until the effective date, Feb. 1, 2011.)
Additionally, 308 codes will be deleted from the list, effective Dec. 1, 2010. Click here to access a list of these codes. (Please note, the codes will still require authorization.
For more information, please refer to the Special Bulletin dated Oct. 27, 2010, and titled “MSBCBS to Update Its List of Procedures Requiring Authorization.”
13 PROVIDERNews Contracting/Reimbursement Update
Updates to the MSBCBS and Please refer to the Mountain State website for an updated list of drugs in the mandatory Medical HHIC Medical Injectable Drug Injectable Drug program. Program 2011 Dental Fee Schedule As communicated previously, the following drugs will be added to the mandatory Medical Injectable Update under Medical or Drug program effective Jan. 3, 2011. Surgical Benefits
J3590 – Actemra (tocilizumab) Mountain State will be updating its dental fee schedule for services that fall under the medical J7186 – Alphanate (antihemophilic factor/von or surgical benefit effective March 1, 2011. As Willebrand factor complex [human]) Mountain State finalizes plans for the update, we J0586 – Dysport (abobotulinumtoxia A) will provide additional information to our provider J1743 – Elaprase (idursulfase) community. 90284 – Hizentra (immune globulin [human]) J7187 – Humate-P (antihemophilic factor/von 2010 Lab Fee Schedule Update Willebrand factor complex [human]) Reminder 90283 – IVIG (intravenous immune globulin [human]) As a reminder, Mountain State generally updates its J0220 – Lumizyme (alglucosidase alfa) Lab Fee Schedule after September (Sept. 1, 2010). Mountain State is currently analyzing the Medicare J1459 – Privigen (immune globulin [human]) Fee Schedule, Ingenix RVUs, and evaluation/ J1680 – RiaSTAP (fibrinogen concentrate [human]) reduction of the Mountain State Market Conversion J3590 – Stelara – (ustekinumab) Factor used for laboratory services. As Mountain State finalizes plans for the update, we will provide J3490 – VPRIV (veraglucerase) additional information to our provider community. J7187 – WILATE (von Willebrand factor/coagulation factor VIII complex [human]) West Virginia Small Business J3590 – Xeomin (incobotulinumtoxinA) Plan (WVSBP) Update The following drugs will be removed from the Medical Injectable Drug program effective Effective Jan. 1, 2011, Mountain State will update Jan. 3, 2011 and will follow the standard method the WVSBP Hospital DRG rates with the PEIA of reimbursement for drugs and biologicals. allowable amounts.
J3355 – Bravelle (urofollitropin for injection) Throughout calendar year 2011, using PEIA pricing for the West Virginia Small Business Plan (WVSBP), J3490 – Cetrotide (cetrorelix acetate) Mountain State Blue Cross Blue Shield will update S012 – Follistim (follitropin beta) all fee schedules within two months of receipt of the S0132 – Ganirelix (ganirelix acetate) appropriate information from the PEIA. These fee S0126 – Gonal – F (follitropin alpha) schedules include RBRVS, DMEPOS, Clinical Lab, Drugs and Biologicals, among others. S0122 – Repronex (menotropins)
Changes in the HCPCS codes made on January 1 or throughout the year for a mandatory drug should (Continued on next page) replace/be used when the prior HCPCS code is no longer valid.
14 October 2010
2011 New Code Update 96152 — health and behavior intervention, each 15 minutes, face-to-face; individual The new codes for 2011 will be adopted by 96153 — health and behavior intervention, each Mountain State effective Jan. 1, 2011, utilizing the 15 minutes, face-to-face; group (2 or more Centers for Medicare & Medicaid Services (CMS) patients) Physician Fee Schedule fully implemented RVU 96154 — health and behavior intervention, each and WV GPCI’s for 2011. The complete annual 15 minutes, face-to-face; family (with patient review of the CMS RBRVS changes and update of present) the Mountain State fee schedule will be effective 96155 — health and behavior intervention, each July 1, 2011. This timing allows Mountain State 15 minutes, face-to-face; family (without the opportunity to review and analyze the changes the patient present) made by CMS. As Mountain State finalizes plans for the annual update we will provide information to According to Current Procedural Terminology our provider community. Lab services are excluded guidelines, evaluation and management services from this update. codes (including preventive medicine, individual counseling codes 99401-99404, and preventive For Highmark Health Insurance Company’s medicine, group counseling codes 99411-99412), (HHIC’s) FreedomBlue PPO, the professional should not be reported on the same day as codes reimbursement will follow the CMS RBRVS 96150-96155. physician fee schedule effective Jan. 1, 2011.
Do not report evaluation and management services on same day as codes 96150-96155
Beginning Feb. 11, 2011, Mountain State Blue Cross Blue Shield and Highmark Health Insurance Company (HHIC) will consider health and behavior assessment or intervention procedure codes 96150-96155 similar to evaluation and management codes.
96150—health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96151 — health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health- oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
15 PROVIDERNews Please Note Important Mountain State Holiday Observances
To assist providers and facilities in planning for the upcoming holidays, the following is a list of Mountain State’s scheduled Thanksgiving, Christmas and New Year’s Day holidays. Providers and facilities are asked to bring this information to the attention of other staff who may need to be aware of these dates.
® Thanksgiving Day, Thursday, Nov. 25, 2010 ® Day after Thanksgiving, Friday, Nov. 26, 2010 ® Day before Christmas (observed) Thursday, Dec. 23, 2010 Although Mountain State’s offices will be closed on ® Christmas Day (observed) Friday, Dec. 24, 2010 these dates, providers still have access to eligibility, ® New Year’s Day 2011 (observed) Friday, benefits, claim status and other key information Dec. 31, 2010 via NaviNet®.
Welcome to Our Newest Groups
Mountain State Blue Cross Blue Shield is pleased to welcome Alcan Rolled Products and Shaft Drillers to the extensive PPO Blue Cross and Blue Shield provider network. Please remember to ask the new members for their Blue Cross and Blue Shield member ID card at the time of service in order to continue efficient claim processing and timely provider reimbursement.
Shaft Drillers Effective Date: 10/1/10 Number of Employees: 266 Group Locations: Morgantown, Bridgeport Product Type: PPO Alpha Prefix: ZPN
Alcan Rolled Products Effective Date: 11/1/10 Number of Employees and Retirees: 2,428 Group Location: Ravenswood Product Type: PPO Alpha Prefix: ALU
16 October 2010 MEDICAL POLICYUPDATES As an added enhancement to our Provider News, Mountain State Blue Cross Blue Shield communicates Medical Policy updates in each issue.
Our medical policies are also available online through NaviNet® or at www.msbcbs.com. An alphabetical, as well as a sectional, index is available on the Medical Policy page. You can search for a medical policy by entering a keyword, policy number or procedure code.
Recent updates or changes are as follows:
December 6, 2010, Effective Date Changed for Policy Policy topic Place of Effective Certain Medical Policy Guidelines Published in number service date August 2010 Provider News S-40 Implantable Inpatient Feb. 21, 2011 Mountain State Blue Cross Blue Shield announced Infusion Pump S-59* Implantable Inpatient Feb. 21, 2011 in the August 2010 Provider News that certain Automatic Outpatient changes would take effect on Dec. 6, 2010, to some Cardioverter- of its medical policy coverage guidelines. Mountain Defibrillator S-77 Endometrial Outpatient Feb. 21, 2011 State is extending the Dec. 6, 2010, effective date Ablation to Jan. 31, 2011 for: S-81 Congenital Cleft Inpatient Feb. 21, 2011 ® Manipulation under anesthesia coverage Palate Repair guidelines explained (page 20) S-82* Intra-arterial/ Inpatient Feb. 21, 2011 intravenous Outpatient ® Reporting guidelines for assisted fertilization Therapeutic services clarified (page 23) Procedures S-88 Ilizarov Bone Inpatient Feb. 21, 2011 ® Cardiac rehabilitation indications and Lengthening contraindications outlined (pages 23 – 24) S-99 Meniscal Allograft Inpatient Feb. 21, 2011 ® Transplant Stereotactic body radiation therapy covered for S-106 Treatment Inpatient Feb. 21, 2011 select conditions (pages 25 – 26) of Urinary Outpatient ® Incontience/ Member risk stratification determines eligibility of Periurethral cardiac rehabilitation sessions (pages 26 – 27) Bulking Agents ® Implantable automatic cardioverter-defibrillators S-113* Pallidotomy and Inpatient Feb. 21, 2011 other Treatments covered if FDA-approved (page 27) of Parkinson’s Disease S-129 Mastectomy and Inpatient Feb. 21, 2011 Reconstructive Place of Service Designation Now Included on Surgery Certain Medical Policies S-130* Cryosurgery of the Outpatient Feb. 21, 2011 Liver Mountain State now adds place of service S-131* Sacral Nerve Outpatient Feb. 28, 2011 designation to some of its medical policies. Modulation/ Stimulation for The following table includes the policy number, the Pelvic Floor policy topic, the eligible place of service, and the Dysfunction effective date of the policy. S-133 Endovascular Inpatient Feb. 21, 2011 Aneurysm Repair Note: For more information about policies S-143 Donor Leukocyte Outpatient Feb. 21, 2011 Infusion for annotated with an asterisk, please see the Hematologic “Additional guidelines” section printed after Malignancies that this table. Relapse after Allogeneic Stem Cell Transplant (Continued on next page)
17 PROVIDERNews S-146* Percutaneous Outpatient Feb. 21, 2011 Urgent coronary angioplasties are typically Vertebroplasty performed inpatient. S-148* Kyphoplasty Outpatient Feb. 21, 2011 S-151 Transmyocardial Inpatient Feb. 28, 2011 Intra-arterial therapeutic procedures performed on (Laser) peripheral vessels, such as femoral arteries and Revascularization (TMR) venous PTA are typically outpatient procedures. S-163 Prophylactic Inpatient Feb. 28, 2011 Mountain State covers these procedures when Mastectomy they’re performed in an outpatient setting. S-167 Lung Volume Inpatient Feb. 21, 2011 Reduction Surgery Intra-arterial therapeutic procedures performed on (LVRS) peripheral vessels, such as femoral arteries and S-178* Treatment of Inpatient Feb. 28, 2011 venous PTA, are not eligible for coverage when Hyperhidrosis S-181* Coronary Inpatient Feb. 28, 2011 they’re performed as an inpatient procedure except Revascularization in specific situations including, but not limited S-183 Partial and Total Inpatient Feb. 28, 2011 to, those clinical situations in which the patient Hip Resurfacing presents with coldness, mottling, pallor, numbness Arthroplasty of the extremity, or pain in the extremity at rest. S-202 Total Ankle Inpatient Feb. 21, 2011 Replacement Additional examples of appropriate criteria for inpatient venous PTA includes oliguria with BUN Additional Guidelines >45 and creatinine >3, or refractory fluid overload. Mountain State will consider each person’s ® Medical Policy S-113, Pallidotomy and Other unique clinical circumstances when a service that Treatments of Parkinson’s Disease, effective is typically performed in an outpatient setting is Feb. 21, 2011 requested to be performed inpatient. Inpatient: Pallidotomy, stereotactic lesion creation In addition to the policies in the previous table, performed on the globus pallidus, is an inpatient some of those circumstances are provided in these procedure. examples: ® Medical Policy S-130, Cryosurgery of the Liver, ® Medical Policy S-59, Implantable Automatic effective Feb. 21, 2011 Cardioverter-Defibrillator, effective Feb. 21, 2011 Outpatient: Cryosurgery of the liver is typically an Inpatient: The implantation of an automatic outpatient procedure. Mountain State covers this cardioverter-defibrillator is performed as an procedure when it’s performed outpatient. inpatient procedure when the procedure is urgent or Cryosurgery of the liver is not eligible for coverage when it is performed by thoracotomy or through the when it’s performed as an inpatient procedure, subxiphoid approach. except in specific situations including, but not Outpatient: Elective, percutaneous procedures limited to, patients with intractable pain or jaundice are typically outpatient procedures. Mountain State with INR >2. covers these procedures when they’re performed ® Medical Policy S-131, Sacral Nerve Modulation/ in an outpatient setting. Mountain State does not Stimulation (SNS) for Pelvic Floor Dysfunction, cover percutaneous procedures when they’re effective Feb. 28, 2011 performed as inpatient procedures. Outpatient: Placement of electrodes used for ® Medical Policy S-82, Intra-Arterial/Intravenous the peripheral nerve stimulation test performed Therapeutic Procedures, effective Feb. 21, 2011 as a component of sacral nerve modulation Inpatient or outpatient: Intra-arterial or intravenous or stimulation for pelvic floor dysfunction is an therapeutic procedures can be performed either outpatient procedure. inpatient or outpatient. ® Medical Policy S-146, Percutaneous Vertebroplasty, effective Feb. 21, 2011
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18 October 2010
Percutaneous vertebroplasty is typically performed 96151—health and behavior assessment (e.g., as an outpatient procedure. It can be performed health-focused clinical interview, behavioral inpatient under special conditions including, but observations, psychophysiological monitoring, not limited to, patients with intractable pain with health-oriented questionnaires), each 15 minutes neurologic deficits such as paresis or paralysis of an face-to-face with the patient; re-assessment extremity. 96152—health and behavior intervention, each ® Medical Policy S-148, Kyphoplasty, effective 15 minutes, face-to-face; individual Feb. 21, 2011 96153—health and behavior intervention, each Kyphoplasty is typically performed as an outpatient 15 minutes, face-to-face; group (two or more procedure. It can be performed inpatient under patients) special conditions including, but not limited to, patients with intractable pain with neurologic deficits 96154—health and behavior intervention, each such as paresis or paralysis of an extremity. 15 minutes, face-to-face; family (with patient present) ® Medical Policy S-178, Treatment of Hyperhidrosis, effective Feb. 28, 2011 96155—health and behavior intervention, each 15 minutes, face-to-face; family (without the Inpatient: Thoracoscopic and open sympathectomy patient present) performed for the treatment of hyperhidrosis is an inpatient procedure. According to Current Procedural Terminology ® Medical Policy S-181, Coronary guidelines, evaluation and management services Revascularization, effective Feb. 21, 2011 codes (including preventive medicine, individual counseling codes 99401-99404, and preventive Inpatient or outpatient: Percutaneous coronary medicine, group counseling codes 99411-99412) artery revascularization can be performed either should not be reported on the same day as codes inpatient or outpatient. 96150-96155. Mountain State considers coronary artery bypass grafting, or percutaneous coronary revascularization performed as an urgent procedure as inpatient Medical Policy Bulletin S-76 (Removal of procedures. Cosmetic Implants) Percutaneous coronary revascularization performed Removal of breast implants covered for certain electively is typically an outpatient procedure. indications. Watch future issues of Provider News for more Effective: Feb. 21, 2011 announcements about place of service additions to Mountain State considers the removal of a silicone Mountain State’s medical policies. gel-filled breast implant medically necessary for the following indications in all cases, that is, when the original insertion of the implants was for cosmetic Do Not Report Evaluation and Management or reconstructive purposes: Services on Same Day as Codes 96150-96155 ® a documented implant rupture Effective: Feb. 21, 2011 ® infection ® Mountain State will consider health and behavior extrusion assessment or intervention procedure codes 96150- ® Baker class IV contracture 96155 similar to evaluation and management codes. ® for implants with severe contracture that 96150—health and behavior assessment (e.g., interfere with mammography health-focused clinical interview, behavioral ® when there is remnant breast cancer or cancer observations, psychophysiological monitoring, in the contralateral breast health-oriented questionnaires), each 15 minutes Mountain State may consider removal of a face-to-face with the patient; initial assessment breast implant associated with a Baker class III contracture medically necessary for patients who (Continued on next page) 19 PROVIDERNews
had originally undergone breast implantation for condition resulting from an accident. Mountain reconstructive purposes. State determines coverage for cosmetic services according to the member’s individual or group Mountain State considers removal of a ruptured customer benefits. A participating, preferred, or saline-filled breast implant medically necessary network provider may bill the member for the only in those patients who had originally undergone denied service. breast implantation for reconstructive purposes. Reconstructive surgery is performed to improve or Mountain State considers the following indications restore functional impairment or to alleviate pain for the removal of implants not medically and physical discomfort resulting from a condition, necessary: disease, illness, or congenital birth defect. ® systemic symptoms, attributed to connective Mountain State usually covers reconstructive tissue diseases, autoimmune diseases, etc. surgery. ® patient anxiety ® pain not related to contractures or rupture Medical Policy Bulletin R-9 (PET and PET/CT A participating, preferred, or network provider may Scanning for Oncologic Indications) not bill the member for services that Mountain Blue Cross Blue Shield has denied as not medically PET and PET/CT scanning for oncologic necessary unless he or she has given advance indications coverage guidelines revised. written notice, informing the member that the Effective: Feb. 21, 2011 service may be deemed not medically necessary and providing an estimate of the cost. The Mountain State is revising its coverage guidelines member must agree in writing to assume financial and payment methodology for PET and PET/CT responsibility, before receiving the service. The scans performed for oncologic indications. The signed agreement should be maintained in the most important changes include: provider’s records. ® a new coverage framework, Mountain State considers the following indications ® expanded covered indications including multiple for removal of implants cosmetic surgery. In these myeloma and bone metastases, cases, the removal is not covered. A participating, ® a clarified position on surveillance, and preferred, or network provider may bill the member ® new modifiers PI and PS. for the denied service. ® Baker class III contractures in patients with The same guidelines apply to both PET and PET/ implants for cosmetic purposes CT. Please see the reference table for a list of tumor types and coverage status. ® rupture of a saline implant in patients with implants for cosmetic purposes Continue reading for more details about each ® removal of an implant solely to replace it with a change. larger or smaller implant 1. Coverage framework Please use procedure code 19328 to report the Mountain State will no longer apply the existing removal of an intact mammary implant. Report four-part structure of diagnosis, staging, restaging, code 19330 for the removal of mammary implant and monitoring response to treatment categories to material. claims for PET and PET/CT scans. Cosmetic surgery is performed to improve an Mountain State will replace this structure with a individual’s appearance and is generally not new methodology using a two-part framework that eligible for payment. However, cosmetic surgery differentiates PET imaging used for the initial may be eligible when it’s performed to correct a
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20 October 2010 anti-tumor treatment strategy from other uses ® a change in patient management to more related to guiding subsequent treatment strategies appropriate palliative care after the completion of initial treatment. These ® a change in patient management to more changes are similar to those made by the Centers appropriate curative care for Medicare & Medicaid Services for the coverage ® improved quality of life and reimbursement of PET and PET/CT scanning. ® improved survival Initial anti-tumor treatment strategy: Mountain State covers PET imaging using the radiopharmaceutical 2. Expanded coverage diagnostic imaging agent fluorodeoxyglucose F-18 Mountain State is expanding coverage of initial (FDG) (procedure code A9552) to determine the or subsequent anti-tumor treatment strategies appropriate initial anti-tumor treatment strategy for for PET to include multiple myeloma and bone patients with brain, breast, colorectal, esophagus, metastases. For bone metastases, Mountain head and neck (excluding central nervous system), State considers PET imaging performed using lung, lymphoma, melanoma, myeloma, ovarian, the radiopharmaceutical diagnostic imaging agent pancreas, Ewing’s and osteogenic sarcomas, sodium fluouride-18 (NaF-18) (procedure code testicular and thyroid cancers, and certain A9580) medically necessary in evaluating areas of situations involving cervical cancer as described. altered osteogenic activity in bone, for patients with For these indications, PET imaging enhances the suspected or biopsy-proven bone metastases. physician’s decision about and planning for an initial anti-tumor treatment strategy and promotes The treating physician will determine when a NaF- improved health outcomes. 18 PET study is needed to plan the initial anti- tumor treatment strategy for bone metastases, or Mountain State will cover one PET study for to evaluate patients with bone pain for suspected patients with solid tumors that are biopsy proven metastases from a known primary tumor, and guide or strongly suspected based on other diagnostic subsequent anti-tumor treatment strategy. Please testing. The patient’s treating physician must include the information documenting the medical determine that a PET study is needed to locate necessity for these studies in the patient’s records. and categorize the extent of the tumor for the These records should be available for review if therapeutic initial treatment strategy when the Mountain State requests them. method of the anti-tumor treatment chosen depends on the extent of the tumor. Mountain State considers PET and PET/CT imaging of tumors in anatomic areas other than Subsequent anti-tumor treatment strategy: PET those covered as not medically necessary. The imaging is also useful in determining a subsequent available scientific evidence is not adequate treatment strategy in patients with brain, breast, to determine whether PET imaging improves colorectal, esophagus, head and neck (excluding physician decision making in anti-tumor treatment central nervous system), lung, lymphoma, strategies or improves a patient’s health outcomes. melanoma, myeloma, ovarian, pancreas, Ewing’s and osteogenic sarcomas, testicular and thyroid 3. Surveillance cancers, and certain situations involving cervical Surveillance PET scanning is a study performed cancer. after the completion of treatment, in the absence However, Mountain State may cover a subsequent of signs or symptoms of cancer recurrence PET study for tumor types other than those listed or progression, for the purpose of detecting above, when the patient’s treating physician recurrence or progression, or predicting outcome. determines that the PET study is needed to The principles of surveillance are similar to those establish the need for and to develop a treatment of traditional screening tests used for the early plan for subsequent anti-tumor treatment. detection of disease. Surveillance has also been Mountain State may ask the provider to submit called “tertiary prevention.” Tertiary preventive medical records and/or additional documentation services are those that are provided to persons to determine coverage in this situation. The documentation should indicate whether the prospective PET scan will lead to: (Continued on next page)
21 PROVIDERNews who have or have had a disease in order to prevent PS—Positron Emission Tomography (PET) or further complications. PET/Computed Tomography (CT) to indicate the subsequent treatment strategy of cancerous tumors Mountain State considers PET performed for when the patient’s treating physician determines surveillance not medically necessary for the that the PET study is needed to plan subsequent following reasons. anti-tumor strategy. ® There are no clinical trials evaluating PET as a method of cancer surveillance to improve patient You must include modifier PI or PS when you report outcomes. an appropriate procedure code for a PET or PET/ CT scan for oncologic indications. ® The sensitivity and specificity of PET scans in the surveillance setting is questionable given the Coverage table possibility of false positives in these situations. PET, a nuclear imaging technology, uses positron ® There is little published literature from clinical emitting radiotracers coupled to organic molecules, trials and studies that address PET for for example, glucose, to obtain both metabolic surveillance. As such, PET is not defined with and physiologic information pertaining to a specific certainty, inadequate direct, or indirect scientific anatomic area. PET scans provide cross-sectional evidence supporting the efficacy of PET images of an anatomic area to identify metabolic, scanning for the purpose of surveillance. biochemical, hemodynamic, pharmacologic, ® Because of the lack of outcome studies and physiologic processes for the diagnosis and supporting the use of PET for surveillance in treatment management of diseases. The following oncology, there are no standardized selection table lists the tumor types and Mountain State’s criteria. coverage position. ® It is unknown how frequently and for which Tumor type Initial treatment Subsequent treatment cancers PET is used for surveillance. Registries strategy (Formerly strategy (Formerly of PET utilization and analysis of claims data “diagnosis” and “restaging” and “monitoring (such as the National Oncologic PET Registry “staging” response to treatment” or NOPR) do not include PET scans used for Cervix Cover, with Cover exception1 surveillance. Colorectal, Cover Cover ® The length of time after the completion of the and related hepatic cancer treatment is not adequately defined to or extra- determine with certainty whether or not a PET hepatic study is performed for surveillance purposes. metastases Esophagus Cover Cover Additional studies are needed to determine the Head Cover Cover usefulness of PET in the surveillance setting and neck (excluding compared to the results obtained using other central diagnostic and imaging techniques. nervous system) 4. New modifiers PI and PS Lymphoma Cover Cover Lung Cover, with Cover Mountain State is also implementing the use of exception2 modifiers PI and PS. These modifiers identify PET Ovary Cover Cover studies performed for initial (PI) or subsequent (PS) Brain Cover Cover anti-tumor treatment strategy. Ewing’s Cover, with Cover sarcoma, exception3 PI—Positron Emission Tomography (PET) or PET/ osteogenic Computed Tomography (CT) to indicate the initial sarcoma Pancreas Cover, with Cover treatment strategy of tumors that are biopsy proven exception4 or strongly suspected of being cancerous based on Testicular Cover, with Not medically necessary other diagnostic testing. exception5
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Tumor type Initial treatment Subsequent treatment oncologic indications are met and the following strategy (Formerly strategy (Formerly conditions are met: “diagnosis” and “restaging” and “monitoring “staging” response to treatment” ® An indeterminate or possibly malignant lesion, Breast Cover, with Cover more than 1 cm and not exceeding 4 cm in (female and exception6 diameter, has been detected (usually by CT); male) and Melanoma Cover, with Cover exception7 ® A concurrent thoracic CT has been performed, Prostate Not medically Not medically necessary which is necessary to ensure that the PET scan necessary is properly coordinated with other diagnostic Thyroid Not medically Cover with exception8 necessary modalities. All other Cover Not medically necessary solid tumors The primary purpose of the PET scan of a solitary Myeloma Cover Cover pulmonary nodule should be to determine the Bone Cover Cover likelihood of malignancy in order to plan the metastases management of the patient. of cancer All other Not medically Not medically necessary 3 Sarcomas: Mountain State considers PET scans cancers not necessary listed herein for Ewing’s sarcoma and osteogenic sarcoma medically necessary for both initial and subsequent Exceptions: There are several guidelines that are anti-tumor treatment strategy for the following applicable to only the anatomic area listed. They conditions: include the following: ® prior to resection of an apparently solitary 1 Cervix: Mountain State considers PET imaging not metastasis medically necessary for initial diagnosis of cervical ® for grading unresectable lesions when the grade cancer related to initial treatment strategy. of the histopathological specimen is in doubt (it is eligible for both initial and subsequent anti-tumor Mountain State covers PET scans as an adjunct treatment strategy) test for the detection of pre-treatment metastasis, that is, in newly diagnosed cervical cancers ® when predictive information, for example, tumor following conventional imaging that is negative for recurrence, response to chemotherapy, is extra-pelvic metastasis. needed to determine clinical management Mountain State covers only one PET scan for 4 Pancreas: Mountain State considers PET staging in patients who have biopsy proven medically necessary in patients with suspected cervical cancer when the patient’s treating pancreatic adenocarcinoma when the results physician determines that the PET study is needed of other imaging modalities, for example, CT, to determine the location and/or extent of the endoscopic retrograde cholangiopancreatography tumor for the diagnostic or therapeutic purposes (ERCP), ultrasonography, are in doubt, described. inconclusive, or equivocal. 2 Lung: Small Cell Lung Cancer (SCL)—Mountain 5 Testicular: Mountain State covers PET for only State considers PET scans medically necessary advanced testicular germ cell tumors in patients for staging of persons with small cell lung cancer with a CT documented residual mass after that has been determined to be clinical stage I SCL chemotherapy treatment and normal or elevated cancer (T 1-2, N0) after standard staging evaluation serum markers to assess for viable tumor, or to (including CT of the chest and upper abdomen, differentiate between fibrosis and/or necrosis. bone scan, and brain imaging). 6 Breast: Mountain State does not consider PET Characterization of Solitary Pulmonary Nodules imaging for diagnosis and initial staging of axillary (SPN)—Mountain State considers PET scans nodes (code G0252) medically necessary. medically necessary for the characterization of 7 Melanoma: Mountain State covers PET to suspected SPNs (ICD-9-CM diagnosis code 793.1) determine the initial treatment strategy for when the general medical necessity criteria for
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23 PROVIDERNews melanoma, except for the evaluation of regional the face and scalp, Mountain State will deny the lymph nodes in melanoma (code G0219). office visit during which the Metvixia was applied. A participating, preferred, or network provider may bill 8 Thyroid: Mountain State covers PET for the member for the denied office visit. subsequent treatment strategy of recurrent or residual thyroid cancer of follicular cell origin How to report Metvixia previously treated by thyroidectomy and radioiodine If you use Metvixia with photodynamic therapy, ablation. The patient must also have a serum submit the complete service on a single claim. thyroglobulin >10ng/ml and a negative I-131 whole Report the first stage (application of the Metvixia) body scan. Mountain State considers all other under the appropriate level of evaluation and uses of PET for subsequent treatment strategy not management service rendered in addition to code medically necessary. J3490, unclassified drugs (for the Metvixia). When If PET and PET/CT scans are performed for you report code J3490, please include a complete oncologic indications not listed as covered, description of the photosensitizing agent you used Mountain State will deny them as not medically in the narrative section of the electronic or paper necessary. A participating, preferred, or network claim. provider may not bill the member for the denied For the second stage (the illumination procedure), service unless he or she has given advance written report only code 96567. Do not report code 17000, notice, informing the member that the service may 17003, or 17004 for this procedure. be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, before Medical Policy Bulletin S-28 (Cosmetic Surgery receiving the service. The signed agreement should vs. Reconstructive Surgery) be maintained in the provider’s records. Reduction mammoplasty coverage criteria explained. Medical Policy Bulletin G-20 (Actinic Keratosis) Effective: Feb. 21, 2011 Metvixia covered as treatment of non- Mountain State considers reduction mammoplasty hyperkeratotic actinic keratoses of face (breast reduction) reconstructive surgery when all and scalp. of the following criteria are met: Effective: Oct. 25, 2010 ® The patient has at least a one-year history of Mountain State has added Metvixia® (methyl significant signs and symptoms that interfere aminolevulinate) cream used in combination with with normal activities, including at least two of the Aktilite CL128 lamp, a narrowband, red light the following: illumination source, to Mountain State Medical back, neck, or shoulder pain not related to Policy G-20, Actinic Keratosis, as eligible for the • other causes such as arthritis, poor posture, treatment of non-hyperkeratotic actinic keratoses of acute strains, etc. the face and scalp. clinical, nonseasonal submammary intertrigo If this treatment is used for diagnoses other than • actinic keratosis, or if it’s used to treat body areas • significant shoulder grooving or shoulder point other than the face or scalp, Mountain State tenderness will deny it as experimental or investigational. A participating, preferred, or network provider may bill • breast hypertrophy the member for the non-covered treatment. • paresthesias of hands or arms When photodynamic therapy with Metvixia is reported for conditions other than actinic keratosis or when Metvixia is applied to areas other than (Continued on next page)
24 October 2010
® These conservative measures have been tried and have not resulted in significant Medical Policy Bulletin B-33 (Female Breast improvement: Reduction Surgery) For back, neck, or shoulder pain, at least six • Female breast reduction coverage criteria weeks of conservative treatment including: revised in addition to the policy number. appropriate support bra • Effective: Feb. 21, 2011 • non-steroid, anti-inflammatory drugs (if Beginning Feb. 21, 2011, Medical Policy B-33 will not contraindicated) be archived. Revised medical necessity criteria for • exercises and heat or cold application female breast reduction surgery will be documented on medical policy S-28. • For submammary intertrigo, at least six weeks of conservative treatment including: • proper hygiene Medical Policy Bulletin Z-24 (Miscellaneous Services) • appropriate medical or pharmacologic treatment Grenz ray therapy considered not medically necessary. • utilization of an appropriate support bra Effective: Feb. 21, 2011 ® There must be an estimated minimum of 350 grams of tissue per breast to be removed from Mountain State considers Grenz ray therapy not women of average height and weight. Cases medically necessary. involving women of significantly smaller stature A participating, preferred, or network provider will be individually considered. may not bill the member for the denied therapy ® Candidates for breast reduction should be at unless he or she has given advance written notice, least 18 years of age. Requests for patients informing the member that the therapy may be under 18 years old will be considered on an deemed not medically necessary and providing an individual basis, due to the sensitive nature estimate of the cost. The member must agree in of performing procedures on the developing writing to assume financial responsibility, before breast. receiving the therapy. The signed agreement should be maintained in the provider’s records. Use procedure code 19318—reduction mammoplasty—to report this surgery. Report Grenz ray therapy with code 77499. When you report code 77499, please include the words Cosmetic surgery is performed to improve an “Grenz ray therapy” in the narrative field of the individual’s appearance and is generally not electronic or paper claim. eligible for payment. However, cosmetic surgery may be eligible when performed to correct a Grenz ray therapy is a form of electromagnetic condition resulting from an accident. Mountain radiation, classified as “ultrasoft” X-ray radiation State determines coverage for cosmetic services that has been used for a variety of inflammatory according to individual or group customer benefits. skin disorders including, but not limited to, eczema A participating, preferred, or network provider may and psoriasis. bill the member for the denied cosmetic surgery. (Continued on next page) Reconstructive surgery is performed to improve or restore functional impairment or to alleviate pain and physical discomfort resulting from a condition, disease, illness, or congenital birth defect. Mountain State usually pays for reconstructive surgery.
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Medical Policy Bulletin (I-27 Certolizumab Medical Policy Bulletin B-58 (Certolizumab {Cimzia®}) {Cimzia®}) Certolizumab covered for Crohn’s disease Cimzia coverage criteria revised in addition to and rheumatoid arthritis. the policy number. Effective: Feb. 21, 2011 Effective: Feb. 21, 2011 Mountain State will provide coverage for Beginning Feb. 21, 2011, Medical Policy B-58 will certolizumab (Cimzia®) when it’s used to reduce be archived. Revised medical necessity criteria for the signs and symptoms of Crohn’s disease and for Cimzia will be documented on Medical Policy I-27. maintaining clinical response in adult patients with moderate to severe active disease who have had an inadequate response to conventional therapy. Medical Policy Bulletin S-89 (Bone Growth Certolizumab is also indicated for rheumatoid Stimulation) arthritis. Electrical bone growth stimulation coverage When certolizumab is a benefit, Mountain State will guidelines modified. cover it when the following criteria are met: Effective: Feb. 21, 2011 ® The member is currently not using another biological DMARD, for example, etanercept Mountain State considers spinal and nonspinal (Enbrel®), anakinra (Kineret®), etc., and electrical bone growth stimulation (EBGS) eligible for payment for certain indications. ® Certolizumab is to be used in reducing signs and symptoms of adult patients with Crohn’s Nonspinal EBGS disease who have failed two alternative Mountain State considers both invasive (operative) therapies or monotherapy with Remicade®, or and noninvasive (nonoperative) nonspinal EBGS ® Certolizumab is to be used alone or in medically necessary as a treatment of fracture combination with methotrexate for the treatment nonunion or congenital pseudoarthrosis in the of adult patients with rheumatoid arthritis. appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper If certolizumab is used for any other diagnosis, extremities, pelvis, and lower extremities). Mountain State will consider it experimental or investigational. It is not covered. A participating, If the member has a diagnosis of nonspinal fracture preferred, or network provider may bill the member nonunion or congenital pseudoarthrosis, he or she for the non-covered service. must meet all of these criteria: ® Report certolizumab with procedure code J0718— At least three months have passed since the Certolizumab pegol, 1 mg. date of the fracture; and, ® Mountain State determines coverage for Serial radiographs have confirmed that no certolizumab according to the individual or group progressive signs of healing have occurred; customer benefits. and, ® The fracture gap is one centimeter or less; and, ® The patient can be adequately immobilized and is of an age likely to comply with non-weight- bearing. Mountain State will deny nonspinal EBGS as not medically necessary if the above criteria are not met.
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Spinal EBGS Medical Policy Bulletin G-41 (Wireless Capsule Endoscopy) Mountain State considers both invasive and noninvasive EBGS of the spine medically Wireless capsule endoscopy of the small necessary as an adjunct to lumbar spinal fusion bowel coverage criteria revised. surgery for members who are considered high-risk for spinal fusion failure when any of the following is Effective: Aug. 16, 2010 met: Mountain State considers wireless capsule endoscopy of the small intestine medically ® A multiple-level fusion entailing three or more necessary for the following indications when vertebrae, for example, L3 to L5, L4 to S1, etc., conventional endoscopic and diagnostic imaging or evaluations, for example, upper gastrointestinal ® Grade II or worse spondylolisthesis, or endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures, are ® One or more failed fusions, or inconclusive: ® One or more of the following risk factors for ® angiodysplasias of the gastrointestinal tract fusion failure are present: (ICD-9-CM diagnosis code 569.85) • gross obesity (BMI greater than 40), ® hereditary gastrointestinal polyposis syndromes • current smoking habit, including familial polyposis (ICD-9-CM diagnosis codes 211.2, 211.3) • diabetes, ® initial diagnosis of suspected Crohn’s disease • renal disease, (ICD-9-CM diagnosis codes 555.0-555.9) • active alcoholism, or ® occult gastrointestinal bleeding, for example, • chronic long-term steroid use iron-deficiency anemia, acute posthemorrhagic anemia, the site of which has not previously Mountain State considers EBGS of the spine not been identified (ICD-9-CM diagnosis codes medically necessary as an adjunct to cervical fusion 280.0, 280.9, 285.1, 562.02, 562.03, 569.86, surgery and for failed cervical spine fusion. 578.0-578.9, 792.1) If EBGS does not meet Mountain State’s medical ® Peutz-Jeghers syndrome (ICD-9-CM diagnosis necessity criteria, Mountain State will consider the code 759.6) services not medically necessary. A participating, preferred, or network provider may not bill the ® suspected or refractory malabsorptive member for the denied service unless he or she syndromes, for example, celiac disease in has given advance written notice, informing the individuals with a negative biopsy (ICD-9-CM member that the service may be deemed not diagnosis codes 579.0-579.9) medically necessary and providing an estimate ® suspected small bowel tumors (ICD-9-CM of the cost. The member must agree in writing to diagnosis codes 152.0-152.9, 209.00-209.03) assume financial responsibility before receiving the service. The signed agreement should be If wireless capsule endoscopy of the small intestine maintained in the provider’s records. is performed for any other conditions, Mountain State will deny the surgery as not medically Please use procedure code 20974 to report necessary. A participating, preferred, or network noninvasive EBGS, and 20975 to report provider may not bill the member for the denied invasive EBGS. service unless he or she has given advance written EBGS promotes osteogenesis of non-united notice, informing the member that the service may fractures, using the application of electrical current at or around the fracture site. (Continued on next page)
27 PROVIDERNews be deemed not medically necessary and providing When you perform a therapeutic massage (97124) an estimate of the cost. The member must agree on separate body regions, unrelated to the in writing to assume financial responsibility, before manipulation procedure, report modifier 59 along receiving the service. The signed agreement should with code 97124. be maintained in the provider’s records. The patient’s medical record must include Wireless capsule endoscopy is limited to documentation identifying the distinct body regions those patients who have undergone complete and diagnoses for which these services were gastrointestinal studies, that is, stool specimen, provided. A region includes all muscles or ligaments upper gastrointestinal endoscopy, and attached to the region being treated. For example, colonoscopy or barium enema, and such studies the trapezius muscle is in the same region as the are inconclusive. Please maintain the results cervical and thoracic spine. of the gastrointestinal evaluations, performed before wireless capsule endoscopy, including all endoscopic and radiologic studies in the patient’s Medical Policy Bulletin Z-64 (Diagnosis and medical record. These records must be available Treatment of Obstructive Sleep Apnea in upon Mountain State’s request. Children) Report wireless capsule endoscopy of the small Coverage and reporting guidelines for the bowel with procedure code 91110—gastrointestinal diagnosis and treatment of obstructive sleep tract imaging, intraluminal (e.g., capsule apnea in children explained. endoscopy), esophagus through ileum, with physician interpretation and report. Effective: Feb. 21, 2011 Diagnosis
Medical Policy Bulletin Y-9 (Manipulation Mountain State covers polysomnography for Services) children and adolescents younger than 18 years of age when it’s performed in the following locations: Therapeutic massage considered part of ® manipulation. in-hospital (tests performed on patients who are admitted as overnight bed patients in a hospital) Mountain State considers therapeutic massage ® (code 97124) an inherent part of a manipulation outpatient (including locations owned or (codes 98925-98929, 98940-98943). This service is controlled by a hospital) not eligible for separate payment when it’s reported ® office (including sleep labs or sleep clinics) on the same day as manipulation. This applies to massages performed manually as well as those Note: Report office place of service only when all performed with a hand-held device. technical costs (technicians, equipment, and office overhead) associated with the polysomnograms are When code 97124 is performed on a separate body the responsibility of the billing physician. region, unrelated to the manipulation procedure, Mountain State considers it for separate payment. Mountain State covers polysomnography for For example, patients may experience referred children for any of the following indications: symptoms, such as sciatica to an extremity caused ® differentiation of benign or primary snoring from by spinal misalignment. In such cases, treatment pathological snoring of the causative diagnosis, for example, spinal misalignment, is medically necessary. However, ® evaluation of disturbed sleep patterns, Mountain State considers separate treatment of excessive daytime sleepiness, cor pulmonale, the extremity medically necessary only if objective failure to thrive, or polycythemia unexplained by findings demonstrate a distinct, unrelated physical other factors or conditions problem with the extremity. Otherwise, Mountain ® when a physician is uncertain whether clinical State will consider the treatment to the extremity as observation of obstructed breathing is sufficient related to the primary service (treatment of spinal to warrant surgery misalignment). (Continued on next page)
28 October 2010
® to determine whether child needs intensive ® If obesity was a major contributing factor and postoperative monitoring following significant weight loss has been achieved, adenotonsillectomy or other pharyngeal surgery repeat testing may be indicated to determine the need for continued therapy. ® child previously diagnosed with obstructive
sleep apnea (OSA) who exhibits persistent Mountain State considers repeat snoring or other symptoms of sleep disordered polysomnography not medically necessary in breathing despite therapy the follow-up of patients with OSA treated with ® titration of continuous positive airway pressure CPAP when symptoms attributable to sleep (CPAP) levels apnea have resolved.
Mountain State considers polysomnography for Mountain State considers the following children not medically necessary for: techniques to diagnose OSA in children ® sleep walking or night terrors experimental or investigational. More randomized-controlled studies are needed to ® routine evaluation of adenotonsillar hypertrophy establish the effectiveness of these tests. A alone without other clinical signs or symptoms participating, preferred, or network provider may suggestive of obstructive sleep disordered bill the member for the denied test. (Note: This breathing is not an all-inclusive list.) ® routine follow-up for children whose symptoms ® Unattended sleep studies (G0400, have resolved post-adenotonsillectomy unless 0203T, 0204T) and unattended portable the preoperative RDI or AHI was greater than 19 polysomnograms (95806, G0398, G0399) or the child continues to snore postoperatively or other symptoms related to preoperative sleep Unattended studies in children using disordered breathing persist or recur commercially available four- to six-channel Mountain State considers repeat polysomnography recording equipment has not been studied. for children medically necessary in the following Portable monitoring based only on oximetry circumstances: is inadequate for identifying OSA in otherwise healthy children. ® Initial polysomnography is inadequate or non-diagnostic and the accompanying ® Sleep studies—polysomnography (95808- caregiver reports that the child’s sleep and 95811) is the only technique shown to quantify breathing patterns during the testing were not the ventilatory and sleep abnormalities representative of the child’s sleep at home; or associated with sleep-disordered breathing in children. ® A child with previously diagnosed and treated OSA continues to exhibit persistent snoring or For a study to be reported as polysomnography, other symptoms of sleep disordered breathing. sleep must be recorded and staged. A sleep In the case of adenotonsillectomy, repeat study that includes three or more parameters polysomnography should also be performed if of sleep other than sleep staging is not a the preoperative OSA was severe (RDI or AHI polysomnogram. Therefore Mountain State does greater than 19). If the treatment was surgical, not cover sleep studies (95807) for diagnosing testing should be deferred for 6 to 8 weeks OSA in children. postoperatively; or ® Multiple sleep latency testing (95805). Multiple ® To periodically re-evaluate the appropriateness sleep latency testing (MSLT) consists of of CPAP settings based on the child’s growth physiological measurements of sleep during a pattern or the presence of recurrent symptoms series of 20 minute naps at two-hour intervals while on CPAP; or performed four to five times in an eight-hour period.
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29 PROVIDERNews
® Other miscellaneous services—other signs and symptoms of OSA. However, Mountain abbreviated or screening techniques, such as State considers intra-oral appliances for treating audio taping and videotaping, daytime nap OSA in patients who do not have craniofacial polysomnography, questionnaires (clinical anomalies experimental or investigational. A assessment), and radiological evaluation, for participating, preferred, or network provider may bill example, MRI, have not been proven to be the patient for the denied appliance. effective in diagnosing OSA in children. There are many different types of appliances that Do not report sleep studies and polysomnography fit into one of two categories: tongue retaining (95805-95811) when the service provided is appliances, and mandibular repositioning a pediatric pneumogram (94772). A pediatric appliances. Mountain State will pay for one pneumogram (94772) provides 12- to 24-hour appliance. Mountain State will deny additional continuous recording of an infant’s respiratory appliances as not medically necessary. However, pattern. The parameters measured may include Mountain State covers replacement of the heart and respiratory rate, oxygen saturation, appliance in case of loss or irreparable damage and/or nasal airflow. Do not report a pediatric or wear when required because of a change in pneumogram (94772) when the service provided is the patient’s condition. In this situation, Mountain an infant apnea monitor with event recording. State requires medical records and/or additional documentation to determine coverage. Medical treatment Surgical treatment Behavior modification—Behavior modification includes avoidance of environmental tobacco Covered surgical treatment smoke and other indoor pollutants, avoidance of ® Adenotonsillectomy—The vast majority of indoor allergens, and treatment of accompanying children with OSA have hypertrophy of the rhinitis. In obese patients, weight loss strategies tonsils and adenoids. The first-line surgical should be used. treatment therefore is adenotonsillectomy. Drug therapy—The success of pharmacological ® Other surgical options available for patients treatment of obstructive sleep apnea syndrome not responding to usual treatment include in children has not been evaluated in controlled uvulopharyngopalatoplasty, craniofacial surgery, clinical trials. Therefore, Mountain State considers and, in severe cases, tracheostomy. it experimental or investigational. A participating, preferred, or network provider may bill the member Non-covered surgical treatment for the denied service. Mountain State considers all other surgical Continuous Positive Airway Pressure (CPAP) interventions experimental or investigational for (E0601)—Mountain State covers CPAP for treating the treatment of OSA in children including, but not children with OSA, for patients with surgical limited to, the following procedures. A participating, contraindications, minimal adenotonsillar tissue, preferred, or network provider may bill the member or persistent OSA after adenotonsillectomy, when for the denied service. definitive surgery is indicated but must await ® complete dental and facial development, or for uvulectomy (42145) those who prefer nonsurgical alternatives. Mountain ® laser-assisted uvuloplasty (LAUP) (S2080) State considers treatment with CPAP under all other circumstances and indications experimental ® somnoplasty or coblation (41530) or investigational. A participating, preferred, or ® Repose System (41512) network provider may bill the member for the denied service. ® injection snoreplasty Intra-oral appliances (E0485, E0486)—when a ® Cautery-Assisted Palatal Stiffening Procedure benefit, Mountain State covers intra-oral appliances (CAPSO) for the treatment of diagnosed OSA sleep apnea for ® Pillar Palatal Implant System pediatric patients with craniofacial anomalies with (Continued on next page)
30 October 2010
® Flexible Positive Airway Pressure device for three months, is found to be maintaining compliance with its use, and is experiencing ® transpalatal advancement pharyngoplasty success in treatment, Mountain State will pay for ® nasal surgery the purchase of the device (after the expenses incurred for the first three month’s rental have ® mandibular distraction osteogenesis been applied to the purchase price). Compliance Mountain State will deny services as not medically is defined as CPAP use of >4 hours per night of necessary if they do not meet its medical necessity use and five nights per week, supported by meter criteria. A participating, preferred, or network readings through a built-in monitoring chip. provider may not bill the member for the denied If the previous criteria are not met, Mountain service unless he or she has given advance written State will deny the CPAP device as not medically notice, informing the member that the service may necessary. A participating, preferred, or network be deemed not medically necessary and providing provider may not bill the member for the denied an estimate of the cost. The member must agree device unless the he or she has given advance in writing to assume financial responsibility, before written notice, informing the member that the receiving the service. The signed agreement should device may be deemed not medically necessary be maintained in the provider’s records. and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, before receiving the device. The Medical Policy Bulletin E-50 (Continuous signed agreement should be maintained in the Positive Airway Pressure (CPAP) provider’s records. Devices Used in the Treatment of Obstructive Mountain State determines coverage for durable Sleep Apnea in Children) medical equipment according to individual or group CPAP devices for treating obstructive sleep customer benefits. apnea in children covered in certain instances. Use code E0601 to report a continuous airway Effective: Feb. 21, 2011 pressure (CPAP) device. Mountain State will consider a continuous Report ICD-9-CM diagnosis code 327.23 to indicate positive airway pressure (CPAP) device medically obstructive sleep apnea (adult) (pediatric). necessary durable medical equipment (DME) when OSAS in children is a disorder of breathing during it’s used in the treatment of otherwise healthy sleep characterized by prolonged partial upper children: airway obstruction and/or intermittent complete ® older than one year with obstructive sleep apnea obstruction (obstructive apnea) that disrupts normal syndrome (OSAS) secondary to adenotonsillar ventilation during sleep and normal sleep patterns. hypertrophy and/or obesity, and The presentation of OSAS in children may differ ® who are not in cardiorespiratory failure when from that of adults. Children frequently exhibit the apnea index is greater than 1 on nocturnal behavioral problems or hyperactivity rather than polysomnography (NPSG), and daytime sleepiness. Daytime sleepiness may occur, but is uncommon in young children. Symptoms ® when any of the following is met: in children may include habitual (nightly) snoring (often with intermittent pauses, snorts, or gasps), • adenotonsillectomy is contraindicated; or disturbed sleep, and daytime neurobehavioral • there is minimal adenotonsillar tissue; or problems. An apnea/hypopnea index (AHI) >1 is considered abnormal—an AHI of 15 is considered • there is persistent OSAS after severe. adenotonsillectomy OSAS can occur in children of all ages, from When the previous criteria are met, Mountain neonates to adolescents. Risk factors include State will pay for the rental of a CPAP device for adenotonsillar hypertrophy, obesity, craniofacial the first three months from the original start date anomalies, and neuromuscular disorders. In of therapy. After the child has been using a CPAP (Continued on next page)
31 PROVIDERNews otherwise healthy children, OSAS is usually or she has given advance written notice, informing associated with adenotonsillar hypertrophy and/or the member that the service may be deemed not obesity. medically necessary and providing an estimate of the cost. The member must agree in writing to The first-line treatment for pediatric OSAS is usually assume financial responsibility, before receiving adenotonsillectomy. CPAP is an option for children the service. The signed agreement should be who are not candidates for surgery or who have an maintained in the provider’s records. inadequate response to surgery. Patients should be re-evaluated postoperatively to determine whether additional treatment is required. Medical Policy Bulletin S-28 (Cosmetic Surgery CPAP is a long-term therapy and requires frequent vs. Reconstructive Surgery) clinician assessment of adherence and efficacy. Panniculectomy and abdominoplasty coverage Left untreated, OSAS can result in complications, criteria clarified. which may include neurocognitive impairment, Effective: Feb. 21, 2011 behavioral problems, failure to thrive, and cor pulmonale, particularly in severe cases. Mountain State will consider panniculectomy and abdominoplasty (“Tummy Tuck”) reconstructive surgery when: Optimal Medical Therapy Required Before ® preoperative photographs document that the Performing Percutaneous Vertebroplasty or panniculus or fold hangs at or below the level of Kyphoplasty the pubis; and Effective: Feb. 21, 2011 ® the patient’s medical records document that Mountain State covers percutaneous vertebroplasty the panniculus or fold causes chronic intertrigo and kyphoplasty when severe debilitating pain (dermatitis occurring on opposed surfaces of or loss of mobility cannot be relieved by optimal the skin, skin irritation, infection or chafing) medical therapy. The patient must meet any of the that consistently recurs or remains refractory to following criteria: appropriate medical therapy, that is, treatment of the rash includes prescription medications, over ® osteoporotic vertebral compression fractures in a period of three months. the cervical, thoracic, and lumbar spine causing moderate to severe pain and unresponsive to Note: The patient must be at least 18 months conservative therapy postoperative following bariatric surgery. ® painful metastasis and multiple lymphoma or How to report panniculectomy and myelomas with or without adjuvant radiation or abdominoplasty procedures surgical therapy ® Report procedure code 15830—excision, ® painful vertebral hemangiomas excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical ® vertebral osteonecrosis panniculectomy—when performing a ® reinforcement of a pathologically weak vertebral panniculectomy. body before a surgical stabilization procedure ® Report procedure codes 15830 and 15847— In addition to the conditions listed above, Mountain excision, excessive skin and subcutaneous State covers kyphoplasty for the treatment of tissue (includes lipectomy), abdomen (e.g., kyphosis. abdominoplasty) includes umbilical transposition and fascial plication — when you perform an If a percutaneous vertebroplasty or kyphoplasty abdominoplasty with a panniculectomy. is performed for any other indications, Mountain State considers it not medically necessary. A ® Report only procedure code 15847 with participating, preferred, or network provider may procedure code 15830. not bill the member for the denied service unless he (Continued on next page)
32 October 2010
® When an abdominoplasty is performed without Administration (FDA) for the treatment of patients panniculectomy, report procedure code 17999. with the following FDA-approved clinical conditions: Include a complete description of the services ® existence of a full (circumferential) Right you performed in the narrative section of the Ventricular Outflow Tract (RVOT) conduit that electronic or paper claim when you report was equal to or greater than 16mm in diameter code 17999. when originally implanted; and, Cosmetic surgery is performed to improve an ® Dysfunctional RVOT conduits with a clinical individual’s appearance and is generally not indication for intervention, and either: eligible for payment. However, cosmetic surgery may be covered when it’s performed to correct ® regurgitation: > moderate regurgitation, or a condition resulting from an accident. Mountain ® State determines coverage for cosmetic services stenosis: mean RVOT gradient > 35 mmHg. according to individual or group customer benefits. If the therapy does not meet these guidelines, A participating, preferred, or network provider may Mountain State will consider it not medically bill the member for the denied surgery. necessary. A participating, preferred, or network Reconstructive surgery is performed to improve or provider may not bill the member for the denied restore functional impairment or to alleviate pain therapy unless he or she has given advance written and physical discomfort resulting from a condition, notice, informing the member that the therapy may disease, illness, or congenital birth defect. Mountain be deemed not medically necessary and providing State usually covers reconstructive surgery. an estimate of the cost. The member must agree in writing to assume financial responsibility, before receiving the therapy. The signed agreement should be maintained in the provider’s records. Medical Policy Bulletin B-35 (Abdominoplasty and Panniculectomy) Report implantation of the Melody transcatheter pulmonary valve with code 33999. When you report Abdminoplasty and panniculectomy coverage code 33999, please include the words “Melody criteria revised in addition to the policy number. transcatheter pulmonary valve” in the narrative field Effective: Feb. 21, 2011 of the electronic or paper claim. Beginning Feb. 21, 2011, Medical Policy B-35 will Melody transcatheter pulmonary valve therapy is be archived. Revised medical necessity criteria used to repair a stenosed or regurgitant pulmonary for abdominoplasty and panniculectomy will be heart valve that has previously been replaced to documented on Medical Policy S-28. correct congenital heart defects. This technology provides a less-invasive means to extend the life of a failed RVOT conduit. Medical Policy Bulletin S-203 (Melody Transcatheter Pulmonary Valve Therapy) Medical Policy Bulletin Z-66 (Telemedicine) Melody transcatheter pulmonary valve therapy eligible for specific indications. Clinician interactive telestroke services now covered. Effective: Sept. 6, 2010 Effective: Nov. 1, 2010 Mountain State considers Melody® transcatheter pulmonary valve therapy medically necessary for Stroke telemedicine, a consultative modality, use as an adjunct to surgery in the management facilitates care of acute stroke patients at hospital of pediatric and adult patients in accordance emergency departments by specialists (vascular with the Humanitarian Device Exemption neurologists) at stroke centers. Evidence-based (HDE) specifications of the U.S. Food and Drug literature supports the use of telemedicine in the form of real-time videoconferencing to deliver acute
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33 PROVIDERNews stroke intervention, that is, telestroke services. where telestroke services are provided to Therefore, Mountain State now covers clinician the patient. interactive telestroke services. The vascular neurologist or radiologist performing Each year, just under 800,000 Americans have a the imaging interpretation services through stroke. The most promising treatment for ischemic teleradiology must be credentialed by Mountain (closed vessel) strokes, which occur in 87 percent State and licensed in the state where the spoke of cases, is a clot-busting drug called a tissue facility is physically located and where telestroke plasminogen activator (tPA). Patients who receive services are provided to the patient. the drug within three hours of stroke onset may CT images must be transmitted in a real-time or have reduced mortality rates and improved long- near real-time mode (less than two minutes) to term speech and motor function. ensure that the telestroke neurologist or radiologist Unfortunately, the application of tPA is not without can collaborate with the spoke facility ordering challenges; tPA must be administered within physician and radiology technicians performing the three hours of stroke onset and cannot be used studies. for hemorrhagic (open vessel) stroke patients ® At a minimum, hub and spoke facilities must for whom the risk of intracerebral hemorrhage, a be connected by broadband or the necessary serious and sometimes fatal complication, is much bandwidth to ensure real-time or near real-time higher. As a result, tPA use is typically limited image acquisition through transmission for final to stroke centers staffed by specialist vascular image display neurologists. ® Hub and spoke facilities must have a PACS Stroke centers are generally located in larger (picture archiving and communications system) urban and academic medical centers; rural and community hospitals can lack comparable staffing ® Hub facilities must have minimum monitor and expertise. However, telemedicine technology resolution (matrix) of 512 x 512 at eight-bit for stroke, known as “telestroke,” allows community pixel depth hospitals to access the expertise of the stroke centers and provide enhanced stroke care, most Technology solutions should include: notably increasing the frequency of administration ® easy-to-use standard features to ensure an of the critical tPA therapy. adequate visualization of the patient and Telestroke technology operates on a “hub and surrounding environment, examination of the spoke” model, in which specialist neurologists at patient, and the opportunity to interact with the stroke center “hub” communicate with “spoke” others at the bedside, including providers and community hospital emergency departments caregivers through video-conference link. During the ® transmission of sufficient quality to support encounter, stroke patients and their physicians standard video resolution, for example, communicate with telestroke specialists using fractional Common Intermediate Format or a battery powered, portable cart with a PC, Source Input Format, equal to or greater than 20 monitor, webcam, and Internet access. Computed frames per second of bi-directional synchronized tomography (CT) scans and other tests conducted audio and video at a resolution capable of being at the spoke facility are shared electronically with accurately displayed on a 13-inch monitor the hub-based specialists. Working together, the specialist and the emergency department Please use the appropriate emergency staff develop a care plan based on established department visit code, 99281-99285, along with stroke protocols including, if appropriate, the the GT modifier—via interactive audio and video administration of tPA. telecommunications system—to report the vascular neurologist’s service. If the patient is an inpatient, The vascular neurologist delivering acute stroke report codes G0425-G0427 (inpatient initial intervention through telestroke services must be telehealth consultations) or G0406-G0408 (inpatient credentialed by Mountain State and licensed in the follow-up telehealth consultations). You should also state where the hub facility is physically located and (Continued on next page)
34 October 2010 report the appropriate ICD-9-CM diagnosis code, ® arthrodesis (fusion) of the contralateral ankle 433.01, 433.21, 433.31, 433.81, 433.91, 434.01, ® 434.11, or 434.91, to indicate telestroke services. inflammatory, for example, rheumatoid, arthritis If the emergency department visit codes and Mountain State will consider total ankle inpatient telehealth consultation codes along with replacement not medically necessary if the previous the GT modifier are reported with any other ICD-9- indications are not met. CM diagnosis code, Mountain State will deny the Total ankle replacement is contraindicated, and services as not covered, A participating, preferred, Mountain State will consider it not medically or network provider may bill the member for the necessary, when any of the following is present: denied service. ® extensive avascular necrosis of the talar dome Please see Mountain State Medical Policy Z-66, Telemedicine, for additional information on ® compromised bone stock or soft tissue telemedicine or telehealth services. (including skin and muscle) ® severe malalignment, for example, greater than 15 degrees, not correctable by surgery Medical Policy Bulletin S-202 (Total Ankle ® Replacement) active ankle joint infection ® Total ankle replacement covered for debilitating peripheral vascular disease end-stage ankle arthritis. ® Charcot neuroarthropathy Effective: Feb. 21, 2011 If Mountain State denies a total ankle replacement Mountain State will consider total ankle as not medically necessary, a participating, replacement medically necessary for the treatment preferred, or network provider may not bill the of debilitating end-stage ankle arthritis when all of member for the denied service unless he or she these indications are met: has given advance written notice, informing the member that the service may be deemed not ® the patient is skeletally mature (skeletal maturity medically necessary and providing an estimate implies radiographic closure of the epiphyseal of the cost. The member must agree in writing to growth plates and cessation of vertical growth); assume financial responsibility, before receiving and the service. The signed agreement should be ® there is moderate to severe ankle (tibiotalar) maintained in the provider’s records. pain that significantly limits daily activity; and Please use procedure code 27702—arthroplasty, ® at least six months of conservative treatment ankle; with implant (‘‘total ankle’’)—to report total (such as anti-inflammatory medication, ankle replacement. physical therapy, splints, or orthotic devices, Total ankle replacement, or arthroplasty, involves as indicated) has been tried and has failed to the surgical removal of a dysfunctional and painful provide improvement; and ankle joint, and replacement with a prosthetic ® an FDA-approved device is used ankle. This procedure has been developed as an alternative to surgical joint fusion. Total ankle At least one of the following indications must also replacement relieves pain and restores joint be present: function or mobility in patients with medically refractory, end-stage degenerative joint disease ® arthritis in adjacent joints, that is, subtalar or that has resulted from conditions such as severe midfoot osteoarthritis, severe post-traumatic arthritis, or ® severe arthritis of the contralateral ankle rheumatoid arthritis. (Continued on next page)
35 PROVIDERNews reimbursing the technical component of diagnostic imaging procedures when one procedure is billed Medical Policy Bulletin B-50 (Total Ankle with another diagnostic imaging procedure in the Replacement) same family. Total ankle replacement coverage criteria Effective Feb. 21, 2011, codes 74261 and 74262 revised in addition to the policy number. will be added to Family 02. Effective: Feb. 21, 2011 Family 02 - CT and CTA (Chest/Thorax/ Beginning Feb. 21, 2011, Medical Policy B-50 will Abdomen/Pelvis) be archived. Revised medical necessity criteria Code Terminology for total ankle replacement will be documented on 74261 Computed tomographic (ct) colonography, Medical Policy S-202. diagnostic, including image postprocessing; without contrast material 74262 Computed tomographic (ct) colonography, diagnostic, including image postprocessing; Medical Policy Bulletin S-9 (Hearing Aids and with contrast material(s) including non- Audiological Testing) contrast images, if performed New reporting guidelines for codes 92550, 92567, and 92568. Medical Policy Bulletin M-7 Effective: Feb. 21, 2011 (Electronystagmography [ENG] and Procedure code 92550—tympanometry and reflex Videonystagmography [VNG] Services threshold measurements—includes tympanometry Coverage criteria revised for ENG services. (impedance testing) (92567) and acoustic reflex testing; threshold (92568). Effective: Feb. 21, 2011 Mountain State will consider 92567 and 92568 Placing of vertical electrodes (92547) will be an components of 92550. When you perform both inherent part of a conventional ENG. Therefore, tympanometry (92567) and acoustic reflex testing when 92547 is reported with any of the ENG (92568) on the same day, report only code 92550. services listed below, (92540-92546, 92700), the charges will be combined and only the ENG Currently, these codes are considered under services(s) will be paid. When reported alone, Mountain State’s similar logic. Mountain State placement of vertical electrodes (92547) will be defines “similar codes” as any code(s) that should denied as a non-covered service. A participating, not be reported with or appended to another code preferred, or network provider cannot bill the by the same provider on the same date of service. member separately for the placing of the vertical electrodes.
Medical Policy Bulletin X-69 (Multiple 1. Basic vestibular evaluation (92540) Procedure Payment Reduction for the Technical 2. Spontaneous nystagmus test, including Component of Certain Diagnostic Imaging gaze and fixation nystagmus, with recording Procedures) (92541) Multiple procedure payment reduction to be 3. Positional nystagmus test, minimum of four applied to diagnostic imaging codes 74261 positions, with recording (92542) and 74262. 4. Caloric vestibular test, each irrigation (binaural, Effective: Feb. 21, 2011 bithermal stimulation, constitutes four tests), Mountain State follows the Centers for Medicare with recording (92543) & Medicaid Services special payment rules for 5. Optokinetic nystagmus test, bi-directional, foveal, or peripheral stimulation, with recording (92544)
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36 October 2010
6. Oscillating tracking test, with recording (92545) classified code 92700, please include the description “Saccades testing” in the narrative 7. Sinusoidal vertical axis rotational testing (92546) section of the electronic or paper claim. Mountain 8. Saccades testing (92700) State covers Saccades testing as a separate component of electronystagmography. Saccades Use procedure code 92700 to report Saccades testing evaluates involuntary abrupt movements of testing. When you report the not otherwise the eyes to test for oculomotor and central nervous system abnormalities. Medicare Advantage MEDICAL POLICY UPDATES
Dec. 6, 2010 effective date changed 96150—health and behavior assessment (e.g., for certain medical policy guidelines health-focused clinical interview, behavioral published in August 2010 Provider observations, psychophysiological monitoring, News health-oriented questionnaires), each 15 minutes Medicare Advantage announced in the August 2010 face-to-face with the patient; initial assessment Provider News that certain changes would take 96151—health and behavior assessment (e.g., effect on Dec. 6, 2010, to some of its medical policy health-focused clinical interview, behavioral guidelines. Medicare Advantage is changing the observations, psychophysiological monitoring, Dec. 6, 2010, effective date to Jan. 31, 2011, for the health-oriented questionnaires), each 15 minutes following articles: face-to-face with the patient; re-assessment Pneumatic compression devices coverage criteria 96152—health and behavior intervention, each changes for Medicare Advantage (pages 31 – 32) 15 minutes, face-to-face; individual Wheelchair options and accessories coverage 96153—health and behavior intervention, each criteria to change (pages 32 – 35) 15 minutes, face-to-face; group (two or more Positive airway pressure devices for the treatment patients) of obstructive sleep apnea policy guidelines revised 96154—health and behavior intervention, each for Medicare Advantage (Pages 35 – 40) 15 minutes, face-to-face; family (with patient More criteria added to Medicare Advantage present) coverage guidelines for external infusion pumps 96155—health and behavior intervention, each (Pages 49 - 50) 15 minutes, face-to-face; family (without the patient present) According to Current Procedural Terminology Do Not Report Evaluation and guidelines, evaluation and management services Management Services on Same Day as codes (including preventive medicine, individual Codes 96150-96155 counseling codes 99401-99404, and preventive Effective: Feb. 21, 2011 medicine, group counseling codes 99411-99412) should not be reported on the same day as codes Medicare Advantage will consider health and 96150-96155. behavior assessment or intervention procedure (Continued on next page) codes 96150-96155 similar to evaluation and management codes.
37 PROVIDERNews
Medicare Advantage Medical Policy Telestroke technology operates on a “hub and Bulletin Z-68 (Telemedicine/Telehealth spoke” model, in which specialist neurologists at Services) the stroke center “hub” communicate with “spoke” community hospital emergency departments Stroke telemedicine covered under Medicare through a video-conference link. During the Advantage. encounter, stroke patients and their physicians Effective: Nov. 1, 2010 communicate with telestroke specialists using a battery-powered, portable cart with a PC, Stroke telemedicine, a consultative modality, monitor, webcam, and Internet access. Computed facilitates care of patients with acute stroke at tomography scans and other tests conducted at the hospital emergency departments by specialists spoke facility are shared electronically with the hub- (vascular neurologists) at stroke centers. Medicare based specialists. Working together, the specialist Advantage now covers telestroke services for its and the emergency department staff develop a members. care plan based on established stroke protocols Unlike other covered telemedicine services, including, if appropriate, the administration of tPA. Medicare Advantage does not limit reimbursement Please use the appropriate emergency for telestroke services to members located in either department visit code, 99281-99285, along with a rural health professional shortage area as defined the GT modifier—via interactive audio and video by §332(a)(1)(A) of the Public Health Services Act telecommunications system—to report the vascular or in a county outside of a metropolitan statistical neurologist’s service. If the patient is an inpatient, area as defined by §1886(d)(2)(D) of the Act. report codes G0425-G0427 (inpatient initial Each year, just under 800,000 Americans have a telehealth consultations) or G0406-G0408 (inpatient stroke. The most promising treatment for ischemic follow-up telehealth consultations). You should also (closed vessel) strokes, which occur in 87 percent report the appropriate ICD-9-CM diagnosis code, of cases, is a clot-busting drug called a tissue 433.01, 433.21, 433.31, 433.81, 433.91, 434.01, plasminogen activator (tPA). Patients who receive 434.11, or 434.91, to indicate telestroke services. the drug within three hours of stroke onset may Please see Medicare Advantage Medical Policy have reduced mortality rates and improved long- Z-68, Telemedicine/Telehealth Services, for more term speech and motor function. information. Unfortunately, the application of tPA is not without challenges. It must be administered within three hours of stroke onset and cannot be used for Medicare Advantage Medical Policy hemorrhagic (open vessel) stroke patients for Bulletin N-64 (Mammography) whom the risk of intracerebral hemorrhage, a How to report mammograms and the GG serious and sometimes fatal complication, is much modifier for Medicare Advantage. higher. As a result, tPA use is typically limited to stroke centers staffed by specialist vascular Effective: Feb. 21, 2011 neurologists. When a screening mammogram changes to a Stroke centers are generally located in larger diagnostic mammogram on the same date of urban and academic medical centers; rural and service, Medicare Advantage considers both community hospitals can lack comparable staffing services eligible for coverage under its Medicare and expertise. However, telemedicine technology Advantage products. for stroke, known as “telestroke,” allows community When a diagnostic mammogram is performed hospitals to access the expertise of the stroke on the same day as a screening mammogram, centers and provide enhanced stroke care, most you must report modifier GG—performance notably increasing the frequency of administration and payment of a screening mammogram and of the critical tPA therapy. diagnostic mammogram on the same patient, same
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38 October 2010 day—along with the appropriate mammogram Medicare Advantage Medical Policy procedure code. Bulletin N-69 (Multiple Procedure Payment Reduction for the Technical If you do not report the GG modifier on the claim, Component of Certain Diagnostic Imaging Medicare Advantage will deny one of the services. Procedures) A provider may not bill the member for the denied service. Please resubmit the claim with the Multiple procedure payment reduction to be appropriate information for reconsideration. applied to diagnostic imaging codes Effective: Feb. 21, 2011 Medicare Advantage Medical Policy Medicare Advantage follows the Centers for Bulletin N-195 (Collagen Meniscus Medicare & Medicaid Services special payment Implant) rules for reimbursing the technical component of diagnostic imaging procedures when one procedure Medicare Advantage considers collagen is billed with another diagnostic imaging procedure meniscus implant not medically necessary. in the same family. Effective: Feb. 21, 2011 Effective Feb. 21, 2011, codes 74261 and 74262 The Centers for Medicare & Medicaid Services will be added to Family 02. (CMS) has issued a national coverage determination that excludes coverage for a collagen Family 02 - CT and CTA (Chest/Thorax/ Abdomen/Pelvis) meniscus implant. CMS considers collagen Code Terminology meniscus implants not medically necessary because the implant does not improve health 74261 Computed tomographic (ct) colonography, diagnostic, including image post-processing; outcomes. This determination will apply to Medicare without contrast material Advantage products. 74262 Computed tomographic (ct) colonography, A provider may not bill a Medicare Advantage diagnostic, including image post-processing; with contrast material(s) including non- member for the denied implant unless he or she contrast images, if performed has given advance written notice, informing the member that the implant may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility before receiving the implant. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider’s records. The collagen meniscus implant (also referred to as collagen scaffold [CS], CMI or MenaflexTM meniscus implant) is manufactured from bovine collagen. It is used to fill meniscal defects that result from partial meniscectomy. After debridement of the damaged meniscus, the implant is trimmed to the size of the meniscal defect and sutured into place to support the generation of new meniscus-like tissue. Use procedure code G0428 to report collagen meniscus implantation.
39 October 2010
Mountain State’s Provider News is designed to serve providers by offering information that will make submitting claims and treating our PROVIDER subscribers easier. We want to know what you would like to see in News upcoming issues of this newsletter. Do you have a question that needs to be answered that you think other providers would be interested in? Are there issues or problems not addressed in this publication? If so, let us know. Send your questions and concerns to:
Mountain State Provider News Post Office Box 1353 Charleston, WV 25325 or call Provider Relations Toll-Free 1-800-798-7768
It is the policy of Mountain State Blue Cross Blue Shield to not discriminate against any employee or applicant for employment on the basis of the person’s gender, race, color, age, religion, creed, ethnicity, national origin, disability, veteran status, marital status, sexual orientation or any other category protected by applicable federal, state or local law. This policy applies to all terms, conditions and privileges of employment, including recruitment, hiring, training, orientation, placement and employee development, promotion, transfer, compensation, benefits, educational assistance, layoff and recall, social and recreational programs, employee facilities, and termination.
Mountain State Blue Cross Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield, and the Cross and Shield symbols and New Blue and SuperBlue are registered service marks and FreedomBlue and BlueRx are service marks of the Blue Cross and Blue Shield Association, an association of Independent Blue Cross and Blue Shield plans. Highmark Health Insurance Company is a wholly owned subsidiary of Highmark Inc.
NaviNet is a registered trademark of NaviNet, Inc., which is an independent company that provides a secure, Web-based portal between providers and health care insurance plans. National Imaging Associates, Inc., is an independent company that administers the Mountain State Radiology Management Program.
Cimzia is a registered trademark of UCB, Inc.
Enbrel is a registered trademark of Amgen Inc. and Pfizer Inc.
Kineret is a registered trademark of Biovitrum AB.
Menaflex is a registered trademark of ReGen Biologics, Inc.
Metvixia is a registered trademark of Galderma S.A.
Remicade is a registered trademark of Centocor Ortho Biotech Inc.
Note: This publication may contain certain administrative requirements, policies, procedures or other similar requirements of Mountain State and Highmark Health Insurance Company (or changes thereto) which are binding upon Mountain State, Highmark Health Insurance Company and its contracted providers. Pursuant to their contract, Mountain State, Highmark Health Insurance Company and such providers must comply with any requirements included herein unless and until such item(s) are subsequently modified in whole or part.
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